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 regulations. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 1/10/25, mandates that a Bed Hold Notice be provided during transfers. However, for four residents (R31, R44, R74, and R95), there was no documented evidence that such notices were given at the time of their respective hospital transfers. Resident R31, with diagnoses including high blood pressure, diabetes, and aphasia, was transferred to the hospital and returned the next day without receiving the required notice. Similarly, Resident R44, diagnosed with anemia, hyperlipidemia, and dementia, was transferred and returned without documentation of the notice. Resident R74, with high blood pressure, coronary artery disease, and seizures, and Resident R95, with atrial fibrillation, parkinsonism, and difficulty walking, also experienced hospital transfers without receiving the necessary bed-hold policy information. The Director of Nursing confirmed the facility's failure to provide the required notifications.
Plan Of Correction
The facility cannot retroactively correct for Resident #26, #31, #44 and #95. Moving forward, the facility will communicate necessary information to the receiving health care provider. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated licensed nursing staff on the regulatory requirements of F625. To monitor and maintain ongoing compliance, the SSD/designee will confirm bed hold policy was sent for residents transferred to hospital 2x weekly x4 weeks, then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.