Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide the required written notice of the bed-hold policy to a resident or their representative upon the resident's transfer to the hospital. This deficiency was identified during an interview with the Nursing Home Administrator (NHA) and a review of clinical records, the facility's bed-hold policy, and interviews with staff and family. The resident, who was cognitively intact with a BIMS score of 15 and had a diagnosed intellectual disability, was transferred to the hospital. Despite the facility's standard practice of sending a copy of the bed-hold policy with the resident during transfers, there was no documented evidence that this was done in this instance. The Business Office Manager (BOM) stated that she provides written bed-hold notifications during business hours, and nursing staff is responsible for this task when she is unavailable. However, no documentation confirmed that this process was completed for the resident in question. The NHA confirmed the failure to provide the required written notice, which deprived the resident and their representative of critical information regarding the bed-hold policy, including the duration and reserve bed payment policy. This oversight potentially compromised the resident's rights and ability to plan for continuity of care.
Plan Of Correction
1. The facility has provided Resident 2/resident representative with the facility bed hold policy via certified mail. 2. The facility has reviewed resident's transfers and discharges for the past 14 days to ensure the bed hold policy has been provided. 3. DON/designee will re-educate licensed nursing staff to the facility process of notifying residents/resident representatives on facility bed hold policy. 4. DON/designee will audit random resident transfers and discharges to ensure the bed hold policy was provided. Audits to be completed weekly for four weeks and monthly for two months. Audits to be submitted to QAPI for review and recommendations.