Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
Transitions Healthcare Allens Cove was found to be non-compliant with the federal requirement 42 CFR Part 483 Subpart B, specifically regarding the notice of bed-hold policy. The facility failed to provide written notice of the bed-hold policy to a resident and/or their representative at the time of transfer to a hospital. This deficiency was identified during a review of the facility's policy, clinical records, and staff interviews. The facility's policy mandates that residents be informed of the bed-hold policy upon admission and again at the time of transfer, with the second notice detailing the duration of the bed-hold policy. However, there was no evidence that such notice was provided to Resident 45 during her hospitalizations on two separate occasions. Resident 45, who has a medical history including hypertension and Type 1 Diabetes Mellitus, was transferred to the hospital on two occasions. Despite the facility's policy requiring written notification of the bed-hold policy at the time of transfer, the Nursing Home Administrator confirmed that there was no documentation indicating that Resident 45 or her representative received this notice during her hospitalizations. This oversight was identified during an interview conducted on April 23, 2025.
Plan Of Correction
1. An audit will be conducted on past discharged residents to identify past deficient practice. 2. Any current residents moving forward will have a bed hold policy signed by resident or documentation on bed hold policy that the policy was explained to resident. 3. A copy of the bed hold policy as well as the bed hold agreement will be placed in a binder at the nurse's station. If a resident must be transferred, the facility form will be completed in person or via phone if required, with the original provided to patient or responsible party and a copy to remain in the chart. 4. DON or designee will provide education to nursing staff on the proper procedure for issuing the bed hold notice. 5. DON or designee will audit all transfers three times weekly x 4 weeks, then two times monthly x 2 months to ensure that the proper bed hold policy is initiated and executed. Results will be taken to the QAPI committee for review of findings and further interventions if warranted.