Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to a hospital for four residents. This deficiency was identified through a review of clinical records and staff interviews. The residents involved had various medical conditions, including cognitive impairments, heart failure, diabetes, metabolic encephalopathy, schizoaffective disorder, bipolar disorder, post-traumatic stress disorder, obstructive uropathy, and renal insufficiency. Each resident was transferred to the hospital for different reasons, such as falls, mental health evaluations, abnormal blood work, and issues with medical devices like nephrostomy tubes. Despite these transfers, there was no documented evidence that the required bed-hold notices were provided to the residents or their responsible parties. The Nursing Home Administrator confirmed that the facility did not issue these notices during the transfers. This oversight was noted for residents who were cognitively impaired, dependent on staff for daily care, or had significant medical and mental health conditions, highlighting a failure to comply with the regulatory requirements for informing residents and their representatives about the bed-hold policy.
Plan Of Correction
Residents 13, 23, 33 and 37 were provided with a copy of the bed hold notice. A baseline audit was completed to identify other residents who were transferred out of the facility for the months of January and February. A binder has been designated to maintain records of bed hold notifications. Education was provided to the Admissions Director on the process for maintaining records of bed hold notification. Monitoring will be captured through auditing notice of transfer and Ombudsman notification of transfer. Two clinical records will be reviewed weekly for 4 weeks, then 4 clinical records 2 times monthly for 2 months. Audits will be conducted by the Admissions Director or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.