Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during a hospitalization event. Specifically, a resident with diagnoses including anemia, coronary artery disease, and hypertension was transferred to the hospital following several episodes of vomiting and diarrhea. Despite the transfer, there was no documented evidence that a written notice of the facility's bed hold policy was provided to the resident or their representative. The facility's policy, dated November 9, 2023, required that a copy of the bed hold retention policy be included with the resident's hospitalization documents. However, the Director of Social Work admitted that they did not send the notification of the facility bed hold policy if a resident was sent to the emergency room and returned without being admitted to the hospital. This oversight was identified during a survey conducted from January 22 to January 30, 2025, and the facility was unable to provide the necessary documentation when requested by the surveyor.
Plan Of Correction
Plan of Correction: Approved March 18, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: Resident was not admitted and returned to (NAME) Neuman within twenty-four hours. Social worker met with resident and family to discuss facility Behold policy. A copy of the Facility Notice of Behold Policy was also provided to the resident and next of kin. To correct the deficient practice, facility will identify all residents who are being transferred to the hospital as those in need to receive the Facility Notice of Behold Policy. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? The Director of Social Work will review the transfer log in PCC to identify whether other residents were potentially affected by the same deficient practice. To correct the deficient practice, facility will identify all residents who are being transferred to the hospital as those in need of receiving the Facility Notice of Bedhold/discharge transfer notification policy. The Revised Bedhold/discharge transfer notification policy was reviewed at Resident Council and Family Council. 3. (NAME) Neuman reviewed and revised the Bed Hold Discharge Transfer Retention Notice Policy. The Bedhold Retention notification and the Hospital Transfer notice have been combined into one notification document. The Director of Social Work provided training and education on the updated policy to Nurse Managers, Unit Clerks, and Social Workers. Nursing Supervisors are responsible for ensuring bed hold/discharge transfer notification letters are provided at the time of transfer. Social services is responsible for issuing bed hold letters for emergent transfers. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change)? To ensure the practice will not re-occur, the Director and/or designee will conduct a weekly audit of the transfer log x 1 month, then monthly x three months. If during the audit it is discovered that a resident did not receive the notice, this will remediate by emailing to family or next of kin. The Director of Social Work or designee will submit results of the audits to the Administrator, and results of the audits will be reported to the QAPI committee monthly for 3 months for action as appropriate.