Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide a bed-hold notice at the time of transfer for three residents who were hospitalized. For Resident #55, the nursing notes indicated a transfer to the Emergency Room for evaluation following an incident, but there was no documentation of a bed-hold notice being provided to the resident or their representative. Although the facility's Admission and Financial Agreement, signed by the resident's family member, described the bed-hold policy, there was no evidence of notification at the time of transfer. Similarly, Resident #60 was transferred to an acute care facility for a medical procedure, but the facility's records did not include a bed-hold notice given to the resident's representative. The Social Services Director admitted to making phone calls to families regarding bed-hold options but did not document these notifications. For Resident #11, who was transferred to a hospital due to a change in condition, there was also no record of a bed-hold notice. The Nursing Home Administrator acknowledged that residents receive the bed-hold policy upon admission and stated that they would review the process with the Social Services Director to ensure proper documentation.
Plan Of Correction
The facility is unable to provide residents #55, #60 and #11 the bed hold notice at the time of their transfer to the hospital since the date of their discharge has passed. Residents #55, #60 and #11 were re-admitted and/or returned to the facility after their emergency discharge to the hospital. Other residents discharged after with a need for an unplanned/emergent transfer/discharge will receive a bed hold form as noted in the facility Bed Hold policy. The facility policy for Bed Hold has been reviewed. On [date], the Director of Nursing/designee initiated education for the nurses, Assistant Director of Nursing, Social Service Director, and Medical Records related to the Bed Hold policy. This education was completed by [date]. The Social Service Director/designee will do a weekly audit for 12 weeks on a minimum of 3 unplanned/emergent transferred residents and/or residents on a therapeutic leave each week. Otherwise, if the facility doesn't have at least 3 unplanned/emergent transferred residents and/or residents on a therapeutic leave for that week, the Social Service Director/designee will complete the weekly audit on the number of transferred/on leave residents that the facility has for that week. This weekly audit will be done to ensure that the facility provided transferred residents written notice on the facility Bed Hold policy for residents who were transferred for hospitalization or those on a therapeutic leave. The Social Services Director/designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and, if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.