Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
Clepper Manor was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the notice of bed-hold policy before and upon transfer of residents. The facility failed to provide written notice of the bed-hold policy to residents or their representatives when residents were transferred to a hospital. This deficiency was identified through a review of clinical records and staff interviews, which revealed that four residents, identified as R5, R8, R15, and R40, did not receive the required written notice of the bed-hold policy upon their transfer to a hospital. The clinical records of these residents showed that they were transferred to an acute care hospital for various medical conditions, including a urinary tract infection, a cardiac event, acute respiratory failure, and a fractured left leg. Despite these transfers, there was no evidence in the clinical records that the residents or their representatives were provided with the necessary written information about the duration and cost of the bed-hold policy. This was confirmed during an interview with the Administrative Nurse, who acknowledged that the bed-hold policy was not provided as required.
Plan Of Correction
No residents negatively impacted. Director of Nursing and Social Service designee did identify residents during the time of survey that were sent out to the hospital that did not receive bed hold notices. Social Service designee was able to correct by providing the notices to those residents. Regional Director of Clinical Operations educated Administrator, Social Service Designee, and Director of Nursing on bedhold letter, policy, and process on 4.15.25. Administrator / designee will educate all nurses on bedhold letter, policy, and process beginning 4.15.25. All education will be completed by 5.1.25. Administrator / designee will audit all resident transfers for 4 weeks to ensure notices are sent with resident (POA if applicable), at the time of transfer or within 24 hours, per regulation and the policy was followed. Audits will begin 4.15.25. Results of audit will be reviewed by QA committee to determine further need.