Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to comply with the regulatory requirement to notify residents or their representatives of the bed-hold policy during hospital transfers or therapeutic leaves. This deficiency was identified for three residents who were transferred to the hospital and subsequently returned to the facility. The facility's policy, dated 1/12/25, mandates that the bed-hold policy be provided at the time of transfer, or within 24 hours in emergencies. However, the clinical records for these residents did not contain documented evidence that such notifications were provided. Resident R21, admitted on 9/14/22, was transferred to the hospital on 10/19/24 and returned on 10/31/24, without receiving the required bed-hold policy notice. Similarly, Resident R30, admitted on 1/24/21, was transferred on 2/21/24 and returned on 2/27/24, and Resident R78, admitted on 10/20/23, was transferred on 12/1/24 and returned on 12/5/24, both without documented notification of the bed-hold policy. The Director of Nursing confirmed the facility's failure to provide the necessary notifications for these residents.
Plan Of Correction
Facility is unable to retroactively send a bed hold policy to Residents #21, #30 and #78 or their RP. Moving forward, the facility will make certain residents/responsible parties will be provided a bed hold policy when a resident is transferred to the hospital. To identify other residents, the DON/designee performed a house audit of current residents in the hospital to ensure Resident/RP were provided a bed-hold policy. There were no negative findings. To prevent this from recurring, the NHA/designee will educate licensed nursing staff and SS on the regulatory requirements of F625 and facility bed-hold policy. To monitor and maintain ongoing compliance, the DON/designee will audit resident transfers 5 days weekly for 4 weeks, then monthly for 2 months to ensure resident or residents' representative are notified of the facility bed-hold policy. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.