Failure to Provide Bed-Hold Policy Notice Upon Transfer
Penalty
Summary
The facility failed to provide Resident R15 and their representative with a written notice of the facility's bed-hold policy at the time of a facility-initiated transfer to a hospital. This deficiency was identified during a clinical record review and staff interview. The nursing note for Resident R15, dated August 6, 2024, indicated that the resident was admitted to the hospital for chest pain. However, there was no documented evidence in the clinical record that the required written notice, detailing the duration of the bed-hold policy, reserve bed payment policy, and the facility's policies regarding bed-hold periods, was provided to the resident or their representative. An interview with the Nursing Home Administrator, Employee E1, confirmed that neither Resident R15 nor their representative received the necessary bed-hold policy information at the time of transfer. Furthermore, it was acknowledged that there was no system in place to ensure that residents and their representatives receive this written notice during such transfers. This oversight is a violation of the regulatory requirements outlined in §483.15(d)(1)(2) and related state codes, which mandate that residents and their representatives be informed of the bed-hold policy before and upon transfer.
Plan Of Correction
1. Unable to retroactively resolve as R15 is already back into the center. R15 was educated of bed hold policy if for future he does require hospitalization. 2. Center unable to retroactively supply bed hold policies. 3. NHA/Designee will educate nursing supervisors on bed hold policies for facility-initiated transfers to the hospital. 4. NHA/Designee will conduct an audit on all facility-initiated transfers 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.