Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice regarding its bed-hold policy to a resident and the resident's representative during a hospitalization event. The resident, who was hospitalized with symptoms suggestive of a stroke, was transferred to the hospital from the facility. Nursing documentation indicated that the resident's sister was informed of the transfer, but there was no evidence that written information about the bed-hold policy was provided to her. A review of the Bed Hold Notice revealed inconsistencies, as it was documented that the resident was unable to sign, and the notice contained conflicting information about the resident's wishes regarding bed retention. The surveyor requested evidence of written communication to the resident's representative, but the facility could not provide it. This failure to provide written notice within 24 hours of the emergency transfer constitutes a deficiency in the facility's compliance with resident rights and responsibilities.
Plan Of Correction
1. Facility cannot retroactively correct bed hold notification to resident 63. 2. Business office manager/designee completed an audit of the last month of discharges and any missed bed hold notifications were addressed. 3. Nursing staff will be re-educated on providing bed hold notification to residents and resident representatives upon transfer out of the facility. 4. DON/designee will conduct random audits of transfers to verify proper bed hold notification weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.