Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by regulations. This deficiency was identified for two residents who were transferred to the hospital. Resident R39, who has dementia, diabetes mellitus, and hyperlipidemia, was transferred to the hospital on 9/9/24 and returned to the facility later. 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. Similarly, Resident R52, who has surgical aftercare needs, muscle weakness, and venous insufficiency, was transferred to the hospital on 10/13/24 and did not return to the facility. The clinical record for Resident R52 also lacked documentation that the resident or their representative was informed in writing about the bed-hold policy. The Director of Nursing confirmed the facility's failure to provide the required notifications for these two hospital transfers.
Plan Of Correction
The bedhold policy is given to all residents upon admission. Residents 39 and 52 were not given a copy of the bed hold policy at the time of their transfer out to the hospital. There were no identified negative outcomes from the deficient practice of the resident/representative not receiving a copy of the bedhold policy at the time of transfer/discharge. The Director of Nursing/designee will educate team members on the need to provide the written bed hold notice before a resident/patient is transferred out of the facility. The Director of Nursing or designee will conduct audits on all discharged residents/residents daily for 4 weeks to ensure the Bed Hold Policy agreement is included with the transfer process and the resident and or the resident's family are aware of the bed hold process. The results of the audits will be presented to the QAPI committee to identify any negative trends toward compliance. The QAPI committee will make further recommendations for improvement, if needed.