Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their own policy. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 12/3/24, mandates that during an emergency transfer or discharge, a notice of transfer and the facility's bed-hold policy must be provided to the resident and their representative. However, for three residents, R17, R18, and R47, there was no documented evidence that such notifications were given during their respective hospital transfers. Resident R17, who had diagnoses including Chronic Obstructive Pulmonary Disease and respiratory failure, was transferred to the hospital multiple times without receiving the required bed-hold policy notification. Similarly, Resident R18, with conditions such as high blood pressure and dependence on supplemental oxygen, and Resident R47, diagnosed with depression and diabetes, were also transferred to the hospital without being informed of the bed-hold policy. The Director of Nursing confirmed the facility's failure to provide the necessary notifications for these hospital transfers.
Plan Of Correction
Resident R17, R18 and R47 suffered no ill effects regarding bed hold policy. Education on the bed hold policy will be provided to nurses by DON or designee on or before 2/11/2025. Audits will be conducted by the DON or designee to ensure the bed hold policy process is being followed 3 x a week x 4 weeks and monthly X 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.