Failure to Notify Residents of Bed-Hold Policy During Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by §483.15(d). This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 5/12/24, mandates that residents or their representatives receive written information about the bed-hold policy at admission and at the time of transfer. However, for two residents, this requirement was not met during their respective hospital transfers. Resident R1, admitted on 1/13/25, was transferred to the hospital on 1/14/25 and returned on 1/15/25. The clinical record lacked evidence of written notification about the bed-hold policy at the time of transfer. Similarly, Resident R2, admitted on 10/23/23, was transferred to the hospital on 1/21/25 and returned on 1/27/25, with no documented evidence of notification. The Director of Nursing confirmed the oversight during an interview, acknowledging the failure to provide the required notifications for both residents.
Plan Of Correction
1. Resident R1 returned to the facility on 1/15/25 and resident R2 returned to the facility on 1/27/25. No negative outcomes to R1 and R2. No charges made to R1 and R2 accounts for bed-hold fees. 2. A retroactive 14-day review of all hospital/leave transfers will be completed to ensure resident/representatives have been provided information regarding the facility bed-hold policy. 3. NHA or designee will educate all licensed nursing staff and social services staff on the facility bed-hold policy and communicating information at time of transfer. 4. NHA or designee will audit all hospital/leave transfers daily x3, then five resident transfers weekly x8 to ensure bed-hold information was provided. Results will be reviewed through QAPI for further recommendation.