Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify appropriate parties about its bed-hold policy upon the transfer of two residents to the hospital. The facility's policy, dated March 18, 2024, mandates that written notice of bed-hold information be provided to each resident and their representative in accordance with state and federal law. However, for Resident 68, who was cognitively intact and required assistance for daily care needs, there was no documented evidence of such notification when she was transferred to the hospital on October 28, 2024, due to difficulty breathing. Similarly, Resident 70, who was cognitively impaired and dependent on staff for daily care needs, was transferred to the hospital on April 3, 2024, after a fall resulted in a bleeding laceration to the back of her head. Again, there was no documented evidence that the resident or her responsible party was notified about the bed-hold policy at the time of transfer. The Nursing Home Administrator confirmed the lack of documentation for both residents, acknowledging that a bed-hold notice should have been issued.
Plan Of Correction
1. The facility cannot retroactively notify of Bed Hold policy. 2. Will review the last 2 weeks of hospital transfers for bed hold notification. 3. The Director of Nursing/Designee will educate licensed staff on Bed Hold Policy and procedure and document education. 4. Audits of notifications will be completed on residents transferred out of facility to hospital 5x per week x2 weeks, Weekly x4, and Monthly x1. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Committee for additional oversight.