Failure to Notify Resident of Bed-Hold Policy
Penalty
Summary
The facility failed to notify a resident or the resident's representative of the bed-hold policy during a hospital transfer. The Admission Agreement requires the facility to provide the bed-hold policy before a resident is transferred to a hospital or for therapeutic leave. Resident R1, who has diagnoses of high blood pressure, diabetes, and difficulty in walking, was transferred to the hospital on 11/22/24. However, the clinical record lacked documented evidence that the resident or their representative received written information about the bed-hold policy at the time of transfer. This deficiency was confirmed by the Director of Nursing during an interview on 12/9/24.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The facility cannot correct that Resident R1 or resident's representative was not notified of the bed hold policy at the time of transfer to the hospital on 11/22/24. 2. The facility will ensure when residents are transferred to the hospital, the resident/representative will be provided written information about the facility bed hold policy. 3. The Nursing Home Administrator/designee will re-educate the business office and social service staff on the facility bed hold policy. The Director of Nursing/designee will re-educate the licensed nursing staff on the facility bed hold policy. 4. The Social Service/Designee will audit resident transfers to the hospital twice weekly for two weeks, weekly for two weeks, and monthly for three months to ensure the bed hold policy is being followed. Results of the audits will be presented to the quality assurance performance improvement committee for review and further recommendations.