Failure to Provide Written Bed Hold Policy Notices
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during transfers to the hospital. This deficiency was identified for five residents who were reviewed for discharge. Specifically, these residents were transferred to the hospital, and the facility could not provide evidence that written notice of the bed hold policy was given to the residents or their representatives. The facility's policy requires that the bed hold policy be communicated both verbally and in writing at the time of admission and transfer. Resident #50, who had intact cognition and was dependent on staff for all activities of daily living, was transferred to the hospital due to respiratory issues. Similarly, Residents #202 and #203, both with moderately impaired cognition and requiring staff assistance, were transferred to the hospital following incidents that necessitated evaluation. In each case, there was no documented evidence that the residents or their representatives received written notice of the bed hold policy. Interviews with the Director of Social Work and the Administrator revealed that there was a service gap and inconsistency in providing these notices, attributed to recent administrative changes.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: ò Review of identified residents revealed that Residents #50, 69, 68 experienced transfers to the hospital and all were readmitted to the facility after completion of acute hospital stay and are current residents. Resident #202 was transferred to the hospital for acute needs and expired in the hospital. Resident #203 was scheduled for discharge to ALF prior to hospital admission and was directly discharged to ALF from acute care hospital. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: ò All residents who were transferred have the potential to be affected, however no residents were negatively impacted. ò An audit of the last 30 days of resident hospital transfers was completed to ensure that a notice of bedhold was given. Element #3: The following system changes will be implemented to prevent reoccurrence: ò The facility policy and procedure on ‘Bed Hold and Notice’ was reviewed and found to be appropriate. ò Social Work staff, medical records, and admissions will be reeducated on the facility policy and requirement for Bed hold notification for all residents and a record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: ò The Director of Social Work has created an audit tool to ensure that Notice of Bed Hold documentation is accurately completed for all hospital transfers/discharges and validate that all required documentation is uploaded to the facility eMAR system. ò The Director of Social Work/designee will audit, and audits will continue until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected immediately and reported to the administrator. ò Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Social Work/designee. Date of Compliance is [DATE].
Penalty
Two residents who were transferred to an acute care hospital did not receive written bed hold notices, nor did their family members or legal representatives. Review of clinical records and staff interviews confirmed the absence of required documentation at the time of transfer.
Staff did not provide written bed hold policy notifications to three residents or their representatives during hospital transfers, as required by facility policy. Record reviews and resident interviews confirmed the absence of these notices, and staff interviews revealed a lack of oversight to ensure the notifications were consistently issued and documented.
Facility staff did not provide a resident and/or the resident's representative with the required written bed-hold policy notification when the resident, who had multiple serious medical conditions and moderate cognitive impairment, was transferred to a hospital. No documentation of the notification was found in the clinical record, and the DON confirmed its absence during the survey.
A resident who was recently hospitalized for shortness of breath was not provided with the required written bed-hold policy before transfer. The NHA confirmed that neither the resident nor their representative received this information, and was unaware of the requirement.
A resident was transferred to a hospital without receiving written notification of the facility's bed-hold policy, and staff confirmed that no such documentation was provided prior to the transfer.
A resident with congestive heart failure was transferred to the hospital multiple times without being provided the required written bed hold notification. Documentation was incomplete or missing for each transfer, with no evidence that the bed hold policy was communicated or acknowledged as required by regulation.
Failure to Issue Written Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, or their family members or legal representatives, when the residents were transferred to an acute care hospital. Specifically, the clinical records for both residents showed that they were transferred and subsequently admitted to a hospital, but there was no documentation that a written bed hold notice was issued at the time of transfer. This was confirmed during an interview with the Market Clinical Advisor, who was unable to locate any evidence of the required notification in the records for either resident. The deficiency centers on the lack of written communication regarding bed hold policy to the residents or their representatives at the time of hospital transfer, as required by regulation.
Failure to Provide Bed Hold Policy Notification at Hospital Transfer
Penalty
Summary
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to the hospital for three out of four sampled residents. According to the facility's own Bed Hold Policy Guidelines, notification is required upon admission, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. Record review showed that for three residents, there was no documentation that a bed hold notice was issued during multiple hospital discharges and readmissions. Interviews with the residents confirmed that they did not receive a bed hold notice at the time of their transfers. Further interviews with facility staff, including the ADON, SSD, DON, and the administrator, revealed that the responsibility for issuing and filing the bed hold notice lies with the charge nurse, with follow-up by the SSD. However, staff were unaware that some notices had not been issued, and there was no clear process to double-check that the notices were consistently provided and documented. The facility census at the time was 88.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
Facility staff failed to provide a resident and/or the resident's representative with the facility's bed-hold policy upon the resident's transfer to a higher level of care. Specifically, for one sampled resident with multiple significant diagnoses, including heart failure, chronic respiratory failure, and cognitive impairment, there was no documented evidence that the required written notification regarding the bed-hold policy was given at the time of transfer to the hospital. A review of the clinical record confirmed the absence of this documentation, and the DON was unable to locate any evidence that the bed-hold policy had been provided. This deficiency was identified through staff interviews, clinical record review, and facility document review, and was discussed with facility leadership during the survey process.
Failure to Provide Bed-Hold Policy Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold policy to a resident or the resident’s representative prior to the resident’s transfer to the hospital. During an interview, the resident confirmed a recent hospitalization and review of the resident’s progress notes documented the transfer for further evaluation of shortness of breath. Subsequent interviews with the Nursing Home Administrator revealed that neither the resident nor their representative received the required bed-hold policy information before the transfer, and the administrator was unaware of the requirement to provide this policy.
Failure to Provide Written Bed-Hold Policy Notification Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to a resident or the resident’s representative prior to the resident’s transfer to a hospital. Medical record review showed that, before the resident was transferred in August 2024, there was no documentation indicating that the required written notification was given. Staff interviews confirmed that neither the resident nor the representative received the facility’s bed-hold policy paperwork or documentation before the transfer occurred.
Failure to Provide Bed Hold Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide proper bed hold notification to a resident who was transferred to the hospital on three separate occasions. Documentation review showed that the required written notice regarding the bed hold policy was not present in the resident's chart for any of the transfers. Specifically, there was no evidence of a completed bed hold notification form, no date or time of notification, no name of the person who provided the notification, and no indication of whether the bed hold was accepted or declined. Additionally, there was no signature from the resident or their representative to confirm that the notification was given. The resident involved had a diagnosis of congestive heart failure and was admitted to the facility in 2025. The resident was transferred to the hospital on three occasions, but in each instance, the facility did not provide the required written information about the bed hold policy as outlined in their own policy and federal regulations. Interviews with medical records staff confirmed the absence of proper documentation and notification for each transfer event.
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