Failure to Provide Required Written Bed-Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a required written Bed-Hold notice to a resident’s responsible party (RP) at the time of the resident’s transfer to a general acute care hospital (GACH). The resident, who had diagnoses including respiratory failure with hypoxia, was originally admitted and later readmitted to the facility, and an H&P dated 2/21/2026 documented that the resident did not have the capacity to understand and make decisions. An MDS dated 3/10/2026 showed the resident was dependent for ADLs such as toileting hygiene, showering/bathing, and bed mobility. The resident was transferred to the GACH for a G-tube replacement, and the discharge summary documented this transfer. Review of the resident’s Bed-hold Informed Consent/Notification Form dated 2/21/2026 showed no indication that a Notice of Bed-hold was provided to the RP after the transfer on 3/10/2026. During interviews, the Business Office Manager stated that the nursing department was responsible for providing the Bed-Hold Notice to residents or their RPs. In a concurrent interview and record review, the DON stated that residents’ beds should be held for seven days when they are transferred to the GACH and that staff would verbally inform RPs about the bed-hold at the time of transfer. The DON also stated she was not aware that written notices should be provided to RPs and acknowledged that, according to the facility’s undated P&P titled “Bed-Holds and Returns,” a written second notice should have been provided to the RP at the time of transfer and that the facility did not follow this P&P. The P&P specified that all residents or representatives are to be provided written information about bed-hold policies at least twice: once in advance of any transfer (e.g., in the admission packet) and a second time at the time of transfer or within 24 hours if the transfer is an emergency.
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