Failure to Notify Resident of Bed-Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to notify the resident or the resident's representative in writing about the bed-hold policy during a transfer to the hospital. This deficiency was identified for one resident, who was cognitively intact and required assistance for daily care needs. The resident experienced a medical event involving large, liquid, and brown emesis, leading to a hospital transfer. Despite the facility's policy to track Medicaid bed hold days and notify appropriate parties, there was no documented evidence that the resident or their responsible party was informed of the bed-hold policy at the time of transfer. The Director of Nursing confirmed the absence of such documentation, acknowledging that a bed hold notice should have been issued.
Plan Of Correction
1. Unable to retroactively provide bed hold for Resident 24. 2. The Interdisciplinary team will review hospital transfers during morning clinical meeting to determine if the bed hold policy was communicated for residents transferred to the hospital. The Social Service Director or designee will complete missed forms upon discovery along with re-education to appropriate staff member. The Director of Nursing/designee will re-educate the Registered Nurse Supervisors including agency, Social Services and Case Manager on the facility's bed hold policy. 3. To maintain and monitor compliance, a weekly audit will be conducted by the Nursing Home Administrator or designee for four weeks and monthly for 2 months on residents transferred to the hospital to determine if the bed hold policy was communicated and documented. 4. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.