Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to a resident and the resident's representative upon the resident's transfer to the hospital. This deficiency was identified during a review of clinical records and a staff interview. Specifically, Resident 2 was transferred to the hospital on November 20, 2024, and later readmitted to the facility. 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. During an interview, the Nursing Home Administrator was unable to provide evidence that the facility informed Resident 2 and their representative of the bed-hold and reserve bed payment policy upon the hospital transfer.
Plan Of Correction
Community cannot correct past practices. To identify residents with the potential to be affected, DON/Designee will audit the last 7 days of discharges to ensure bed hold policy requirement is met. To prevent from re-occurring, DON/designee will educate licensed staff on bed hold policy requirement. DON/designee will educate BOM to ensure paperwork has been received timely. To monitor and maintain compliance, DON/designee will audit 3 transfers per week x 4 then monthly x 2 to ensure bed hold policy has been received. All findings will be brought to QAPI committee.