Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of its bed-hold policy to a resident and/or the resident's representative at the time of transfer to a hospital. This deficiency was identified during a review of clinical records and staff interviews. Specifically, a nursing note dated March 16, 2024, documented that a resident was transferred to the hospital due to a change in condition. However, there was no documented evidence that the resident or their representative received written information about the facility's bed-hold policy at the time of transfer. An interview with the Director of Nursing on January 24, 2025, confirmed the absence of such documentation.
Plan Of Correction
The facility cannot retroactively correct this deficiency. A house-wide audit will be conducted to ensure the bed hold policies were reviewed with resident or resident representatives. All licensed staff will be educated on the updated Bed Hold policy with emphasis on including the policy at the time of transfer and leave. The Nursing Home Administrator or designee will audit all transfers and therapeutic leaves for 4 weeks. Also, the administrator will audit 3 months of the monthly reports to the Office of the State Long-Term Care Ombudsman. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.