Failure to Provide Written Bed Hold Policy Notices
Penalty
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].