Failure to Inform Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that a resident's representative was informed of the bed hold policy before and upon the resident's transfer to a hospital. This deficiency involved a resident with severe cognitive impairment who was transferred to the hospital due to shortness of breath and wheezing. The facility's policy required that both the resident and their representative receive written information about the bed hold policy and payment details at admission and before any hospital transfer. However, upon review of the resident's medical record, it was found that neither the resident nor their representative received the necessary written information regarding the bed hold policy. During an interview, the Director of Social Services acknowledged that the social workers, who were responsible for providing this notice, did not complete the task.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: ò No immediate action could be taken for residents found to be affected. Identification of other residents having the potential to be affected was accomplished by: ò Residents who are placed on leave or transferred out of the facility, planned or unplanned, have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: ò Director of Social Services or designee will identify and implement a compliant Bed Hold Form by 3/20/25. ò Administrator or designee will in-service Social Services Staff on the issuance of Bed Hold Notices before or upon transfer by 3/31/25. ò Director of Nursing or designee will in-service Licensed Nursing Staff on the issuance of Bed Hold Notices before or upon transfer by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: ò Director of Social Services or designee will audit 100% of resident transfers and overnight leaves of absence for written notification of the facility bed hold policy to resident or resident representative. Beginning on 4/1/25 audits will be weekly x4 weeks and then Monthly x 3 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Social Services