F0628

B

Failure to Provide Required Bed-Hold Policy Notices at Time of Hospital Transfer

Canonsburg, Pennsylvania Survey Completed on 04-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required written notice of its bed-hold policy to residents and/or their representatives at the time of transfer to the hospital or for therapeutic leave, as required by 42 CFR §483.15(d). Federal regulation specifies that facilities must issue two notices related to bed-hold policies: one that may be provided in advance (such as in the admission packet) and a second written notice that must be given to the resident and, if applicable, the resident’s representative at the time of transfer, or within 24 hours in cases of emergency transfer. The notice must explain the duration of any bed-hold, the reserve bed payment policy, and information about the resident’s right to return to the next available bed. For three of six residents reviewed for hospitalization, the clinical records did not contain documentation that this second written bed-hold notice was provided at the time of transfer.

One resident, identified as R8, was admitted with diagnoses including heart failure and a history of stroke, and had moderate cognitive impairment per the MDS. A progress note documented that the resident’s wife requested transfer to the ER due to the resident’s decline, including poor oral intake, vomiting with attempts to eat or drink, and worsening lab results, leading to a 911 call and transfer. Review of this resident’s clinical record did not show any notation that written bed-hold information was provided to the resident or the resident’s representative upon this transfer.

Another resident, identified as R15, had COPD and a communication deficit, with severe cognitive impairment noted on the MDS. A progress note described the resident leaving via EMS to a local hospital for evaluation and treatment of the right leg, with the wife and brother-in-law present and reportedly satisfied with the plan of care. A later note documented that the resident’s hemoglobin was 5.5 and that the resident was sent to the hospital for a transfusion, with family made aware of the results and transfer. For both of these hospital transfers, the clinical record lacked documentation that written bed-hold notification was provided to the resident or representative.

A third resident, identified as R30, had diagnoses including high blood pressure and a history of stroke, with severe cognitive impairment documented on the MDS. One progress note described a nurse finding the resident slumped over on the commode, unresponsive compared to baseline, drooling, and not following commands, after which the nurse practitioner was notified and the resident was sent to the hospital via squad for evaluation. Another note documented that the resident was seizing, had received medication without effective results, and that 911 was called; EMTs administered medication via an internal jugular line, stopped the seizure, and transported the resident to the hospital, while attempts to reach the son were unsuccessful and the provider was notified. For both of these transfers, the clinical record did not contain notation that written bed-hold notification was provided. In an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to ensure that residents and/or their representatives received written notice of the facility bed-hold policy at the time of transfer for three of six residents reviewed.

Plan Of Correction

The facility will ensure that the residents and/or their representatives receive written notice of the facility bed-hold policy at the time of transfer.

Resident R 15 has been discharged from the facility.

The BOM educated resident R8 and R30 to the facility bed hold policy

Before a resident is transferred to a hospital or the resident goes on therapeutic leave, the nursing facility will provide written information to the resident or resident representative that specifies the bed hold policy.

Residents on admission will receive a copy of the facility bed hold policy which will be signed by the resident and uploaded into the medical record.

When a resident is transferred to a hospital or is on therapeutic leave the BOM will notify the resident/representative by phone the next day to explain the facility's bed hold policy and confirm whether the resident wants to maintain a bed in

the facilityThe DON/Designee will educate the nursing supervisors on the requirement to send a copy of the bed hold policy with the resident on transfer to hospital or on a therapeutic leave

Audits will be completed to ensure the bed hold notice was provided and completed promptly for 90% of residents transferring to a hospital or on a therapeutic leave.These Audits will occur weekly times four then monthly times three. Results will be reviewed at the QAPI committee meeting for further recommendations