F0628

D

Failure to Implement Bed-Hold Policy for Hospitalized Resident

Los Angeles, California Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The facility failed to implement its bed-hold policy for a resident who was transferred to a general acute care hospital (GACH). The resident was admitted with diagnoses including hemiplegia, major depressive disorder, seizures, and malignant neoplasm of the parietal lobe. A physician’s order dated 3/20/2026 authorized transfer to a GACH for further evaluation, and the discharge summary showed the resident was transferred out via medical transport the day after admission. Review of the facility census and transfer documentation on 3/24/2026 showed that no bed hold was initiated at the time of transfer.

During interviews and concurrent record reviews, the DON confirmed that the census dated 3/23/2026 did not indicate a bed hold for this resident and stated there should have been a seven-day bed hold from the date of transfer. The Business Office Manager, who stated the business office is responsible for bed holds and that bed holds are indicated by placing the resident’s name as a placeholder on the census, acknowledged that the census from 3/20/2026 to 3/24/2026 did not show a bed hold and admitted to accidentally discharging the resident, calling it an oversight. The Administrator stated that once a resident is sent out, the facility should hold the resident’s bed for seven days regardless of the resident’s status of returning. The facility’s policy and procedures titled “Bed-Holds and Returns” indicated that prior to a transfer, written information must be given to the resident and representative explaining bed-hold rights and limitations, reserved bed payment policies, and details of the transfer, but the report identifies a failure to reserve the bed in accordance with this policy and regulatory requirements.