Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents or their representatives upon transfer to a hospital, as required by §483.15(d). This deficiency was identified through a review of clinical records and staff interviews. Specifically, two residents, identified as Resident R47 and Resident R76, were transferred to the hospital without documented evidence that they or their representatives received the necessary written information about the facility's bed hold policy. Resident R47, who had diagnoses including intellectual disabilities, dementia, and major depressive disorder, was transferred to the hospital and returned to the facility without the required notification. Similarly, Resident R76, with diagnoses of high blood pressure, depression, and dementia, was transferred to the hospital and did not return, also without documented evidence of receiving the bed hold policy notification. The Nursing Home Administrator confirmed the absence of this documentation during an interview.
Plan Of Correction
1. Facility is unable to go back and make certain that all hospital transfers were provided with written information on the facility's bed hold policy at the time of transfer. 2. Moving forward residents will be provided with the bed hold policy at the time of transfer to the hospital/therapeutic leave of absence. 3. DON/designee to educate nursing staff on the need to provide residents with the bed hold policy and bed hold/transfer documents at the time of transfer to the hospital or therapeutic leave of absence and to document in EHR that bed hold policy was provided. 4. IDT will audit the medical record during daily stand up meeting to ensure the transfer note includes reference to the bed hold policy being issued to the resident prior to discharge. 5. DON/designee to audit transfer notes and bed hold policies 1x/week for 4 weeks. 6. Results to be submitted to QAPI for review and approval.