Failure to Provide Bed-Hold Policy Notices
Summary
The facility failed to provide residents or their representatives with a copy of the bed-hold policy upon transfer to a hospital or therapeutic leave. This deficiency was identified through clinical record reviews, facility policy reviews, and staff interviews. Specifically, seven out of ten residents reviewed for hospitalization did not receive the required bed-hold notice. The facility's policy, last revised in March 2022, mandates that all residents or their representatives be given written information regarding the bed-hold policy at the time of transfer or within 24 hours if the transfer was an emergency. However, this policy was not followed for Residents 4, 32, 35, 63, 71, 72, and 89 during their respective hospital transfers between October 2023 and March 2024. For instance, Resident 4, who has diagnoses including hypothyroidism and vascular dementia, was transferred to a hospital emergency room on October 1, 2023, due to chest pain. The facility could not provide documentation that Resident 4 or their representative received the bed-hold policy notice. Similar deficiencies were found for Resident 32, who was transferred to the hospital multiple times in January 2024 due to a change in condition, and Resident 35, who was transferred on February 2, 2024. In each case, the facility failed to provide the required bed-hold notice. Further examples include Resident 63, who was admitted to the hospital on January 23, 2024, and Resident 71, who was transferred on January 5, 2024, due to possible pneumonia. Both residents' records lacked evidence of the bed-hold policy being provided. Resident 72, transferred on December 5, 2023, and Resident 89, admitted to the hospital on December 12, 2023, and March 8, 2024, also did not receive the bed-hold policy notice. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the facility's awareness of this issue and the lack of documentation for these transfers.
Penalty
Two residents who were transferred to an acute care hospital did not receive written bed hold notices, nor did their family members or legal representatives. Review of clinical records and staff interviews confirmed the absence of required documentation at the time of transfer.
Staff did not provide written bed hold policy notifications to three residents or their representatives during hospital transfers, as required by facility policy. Record reviews and resident interviews confirmed the absence of these notices, and staff interviews revealed a lack of oversight to ensure the notifications were consistently issued and documented.
Facility staff did not provide a resident and/or the resident's representative with the required written bed-hold policy notification when the resident, who had multiple serious medical conditions and moderate cognitive impairment, was transferred to a hospital. No documentation of the notification was found in the clinical record, and the DON confirmed its absence during the survey.
A resident who was recently hospitalized for shortness of breath was not provided with the required written bed-hold policy before transfer. The NHA confirmed that neither the resident nor their representative received this information, and was unaware of the requirement.
A resident was transferred to a hospital without receiving written notification of the facility's bed-hold policy, and staff confirmed that no such documentation was provided prior to the transfer.
A resident with congestive heart failure was transferred to the hospital multiple times without being provided the required written bed hold notification. Documentation was incomplete or missing for each transfer, with no evidence that the bed hold policy was communicated or acknowledged as required by regulation.
Failure to Issue Written Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, or their family members or legal representatives, when the residents were transferred to an acute care hospital. Specifically, the clinical records for both residents showed that they were transferred and subsequently admitted to a hospital, but there was no documentation that a written bed hold notice was issued at the time of transfer. This was confirmed during an interview with the Market Clinical Advisor, who was unable to locate any evidence of the required notification in the records for either resident. The deficiency centers on the lack of written communication regarding bed hold policy to the residents or their representatives at the time of hospital transfer, as required by regulation.
Failure to Provide Bed Hold Policy Notification at Hospital Transfer
Penalty
Summary
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to the hospital for three out of four sampled residents. According to the facility's own Bed Hold Policy Guidelines, notification is required upon admission, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. Record review showed that for three residents, there was no documentation that a bed hold notice was issued during multiple hospital discharges and readmissions. Interviews with the residents confirmed that they did not receive a bed hold notice at the time of their transfers. Further interviews with facility staff, including the ADON, SSD, DON, and the administrator, revealed that the responsibility for issuing and filing the bed hold notice lies with the charge nurse, with follow-up by the SSD. However, staff were unaware that some notices had not been issued, and there was no clear process to double-check that the notices were consistently provided and documented. The facility census at the time was 88.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
Facility staff failed to provide a resident and/or the resident's representative with the facility's bed-hold policy upon the resident's transfer to a higher level of care. Specifically, for one sampled resident with multiple significant diagnoses, including heart failure, chronic respiratory failure, and cognitive impairment, there was no documented evidence that the required written notification regarding the bed-hold policy was given at the time of transfer to the hospital. A review of the clinical record confirmed the absence of this documentation, and the DON was unable to locate any evidence that the bed-hold policy had been provided. This deficiency was identified through staff interviews, clinical record review, and facility document review, and was discussed with facility leadership during the survey process.
Failure to Provide Bed-Hold Policy Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold policy to a resident or the resident’s representative prior to the resident’s transfer to the hospital. During an interview, the resident confirmed a recent hospitalization and review of the resident’s progress notes documented the transfer for further evaluation of shortness of breath. Subsequent interviews with the Nursing Home Administrator revealed that neither the resident nor their representative received the required bed-hold policy information before the transfer, and the administrator was unaware of the requirement to provide this policy.
Failure to Provide Written Bed-Hold Policy Notification Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to a resident or the resident’s representative prior to the resident’s transfer to a hospital. Medical record review showed that, before the resident was transferred in August 2024, there was no documentation indicating that the required written notification was given. Staff interviews confirmed that neither the resident nor the representative received the facility’s bed-hold policy paperwork or documentation before the transfer occurred.
Failure to Provide Bed Hold Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide proper bed hold notification to a resident who was transferred to the hospital on three separate occasions. Documentation review showed that the required written notice regarding the bed hold policy was not present in the resident's chart for any of the transfers. Specifically, there was no evidence of a completed bed hold notification form, no date or time of notification, no name of the person who provided the notification, and no indication of whether the bed hold was accepted or declined. Additionally, there was no signature from the resident or their representative to confirm that the notification was given. The resident involved had a diagnosis of congestive heart failure and was admitted to the facility in 2025. The resident was transferred to the hospital on three occasions, but in each instance, the facility did not provide the required written information about the bed hold policy as outlined in their own policy and federal regulations. Interviews with medical records staff confirmed the absence of proper documentation and notification for each transfer event.
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