Deficiency in Bed-Hold Notice Provision
Penalty
Summary
The facility failed to provide the required bed-hold notices upon transfer or discharge for several residents, as evidenced by clinical record reviews and staff interviews. Specifically, two residents did not receive a copy of the facility's bed-hold notice upon transfer or discharge, and five residents received notices that lacked necessary information. The missing information included the duration of the state bed-hold policy and the reserve bed payment policy, which are required by regulations. Resident 1, who had diagnoses including heart failure and chronic kidney disease, was transferred to the hospital, but the bed-hold notice provided did not include the required information about the state bed-hold duration or reserve bed payment. Similarly, Resident 28, with diagnoses of heart failure and dementia, was transferred multiple times without receiving complete bed-hold notices. In one instance, the facility failed to provide any bed-hold notice at all. Staff interviews confirmed these omissions and acknowledged the failure to include necessary details in the notices. Additional residents, including Residents 52, 53, 58, and 69, also experienced similar deficiencies. Resident 52, with hypertension and diabetes, was transferred to the hospital, but the notice lacked information on the state bed-hold duration and reserve payment. Resident 53, who suffered a fall, did not receive a bed-hold policy notice upon transfer. Resident 58 and Resident 69 also received incomplete notices, missing critical information about the bed-hold policy. Staff interviews further confirmed these deficiencies, highlighting a systemic issue in the facility's handling of bed-hold notices.
Plan Of Correction
1. Unable to retroactively correct the clinical record for R28 and R53 to provide clinical record of the facility's bed-hold notice upon date of transfer or discharge from the facility. Both residents continue to reside at the facility. Unable to retroactively correct the clinical record for R1, R28, R52, R58 and R69 to provide bed-hold notices that included the required information upon transfer; residents continue to reside at the facility. R69 no longer resides at the facility, no adverse effects related to practice. 2. All residents have the potential to be impacted. R1, 28, 52, 53, and 58 immediately will be given the form regarding Bed Hold Notice regulation no later than March 14, 2025 or any need for bed hold notice immediately of Transitions of Care Policy and Procedure, Admission, Transfers, and Discharge for the Resident and/or Resident Representative. R69 no longer resides at the facility, no adverse effects related to practice. 3. Facility wide Audits of all bed hold transfers or discharges for the past 3 months will be conducted by the DON and/or Shift Supervisor. Any residents who do not have the appropriate information on the bed transfer form will be given a new form with the revised information by March 14, 2025. 4. The DON will in-service the Shift Supervisor upon emergent transfer to the hospital to provide the Notice of Bed Hold form to the resident by March 14, 2025. The Shift Supervisor is to then complete a progress note stating it was provided, and to whom. DON will educate the Shift Supervisors on the revised Notice of Bed Hold Form to the resident upon emergent transfer to the hospital, and document in a progress note in the EHR (PCC) System that it was given. 5. Social Worker Director and DON will conduct a record audit via the progress notes of all residents who have emergent bed-hold notices upon transfer or discharge to the hospital and audit the transfer and discharge log to be sent to the Ombudsman daily x 3 to ensure the Notice of Residents Transfer or Discharge form was given and signed appropriately, to whom until 100% completion is achieved. Audits will continue x2 weekly, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.