Failure to Provide Bed-Hold Policy Notice Upon Resident Transfer
Penalty
Summary
The facility failed to provide a written notice of its bed-hold policy to a resident or the resident's responsible party upon transfer to a hospital. This deficiency was identified during a clinical record review and staff interview. Specifically, Resident 4 was transferred to the hospital from December 3 to 9, 2024, due to a change in condition. However, there was no documentation available indicating that the facility provided the required written notice regarding the bed-hold policy to the resident or the resident's responsible party at the time of transfer. An interview with Employee 4, a registered nurse supervisor, confirmed the absence of documentation for the bed-hold policy notice for Resident 4. This oversight was noted as a failure to meet the regulatory requirement outlined in §483.15(d)(1)(2), which mandates that nursing facilities provide written information about the bed-hold policy before and upon transfer of a resident.
Plan Of Correction
1. Facility can not retroactively correct. 2. The facility conducted a 30-day review of any hospital transfers to determine if any other residents were missing documentation of written bed-hold notifications. Any identified deficiencies were immediately corrected if able. 3. NHA educated Social Services whom received re-education on proper hospital transfer notification, which include: - The timing of the notice (must be provided at the time of transfer). - Documentation requirements to ensure the notice is placed in the resident's clinical record. - Resident and responsible party acknowledgment procedures. Licensed staff re-educated on the facilities Hospital Transfer Checklist which was re-implemented, requiring the nurse overseeing the transfer to confirm that the bed-hold notice was provided and documented on the Transfer out checklist. 4. The Director of Nursing (DON) or designee will audit 5 random hospital transfers per month for three months to verify that: - A written bed-hold notice was provided to the resident and/or responsible party. - Documentation was properly signed and checklist was filed in the clinical record. Audit results will be reviewed by the QAPI team monthly to determine the need for ongoing monitoring.