Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required by regulations. This deficiency was identified through a review of clinical records and staff interviews, which revealed that three residents, identified as Residents 27, 124, and 102, were transferred to the hospital without receiving the necessary written information about the facility's bed-hold policy. Resident 27 was transferred on November 27, 2024, Resident 124 on November 26, 2024, and Resident 102 on December 10, 2024. The Clinical Operations Executive confirmed the absence of documented evidence of the provision of this information during an interview conducted on January 23, 2025.
Plan Of Correction
1. Residents 27, 102, and 124 are MA or MAP residents and did not lose their assigned beds while out at the hospital. We are unable to correct those past occurrences. 2. All residents who transfer out to the hospital or on therapeutic leave have the potential to be affected by deficient practice. 3. All nursing staff will be educated regarding the bed hold policy and procedure. The business office and social services have been educated regarding the electronic completion of the bed hold notice. 4. Business Office Manager or designee will audit all transfers out of the building and therapeutic leaves daily during the business week for four (4) weeks then weekly until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.