Failure to Provide Written Bed-Hold Policy Notice Upon Hospital Transfer
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident or their representative with written notice specifying the duration of the bed-hold policy prior to or immediately following the resident's transfer to the hospital. The resident in question was a 72-year-old individual with multiple diagnoses, including liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. The resident was cognitively intact at the time of transfer, as indicated by a BIMS score of 13. Documentation showed that the resident requested to go to the emergency department and was transferred accordingly, but there was no evidence in the medical record that the required bed-hold policy notice was given. Interviews with facility staff, including the Nursing Home Administrator and the Director of Nursing, confirmed that they could not locate any documentation showing that the bed-hold policy had been presented to the resident or their representative. The DON initially stated that the Admissions Coordinator had discussed the policy with the resident and family, but later clarified that there was no documentation of such a discussion. The only related communication found was an email indicating the resident would not be returning to the facility, as they were being transferred to hospice care. A review of the facility's own policy confirmed that written notice of the bed-hold policy should be provided at the time of transfer and a signed copy kept in the resident's file. However, in this case, there was no evidence that the policy was communicated or documented as required, resulting in noncompliance with federal regulations regarding notice of bed-hold policy upon transfer.
Plan Of Correction
Resident #47 no longer resides in the facility. An investigation of the event was completed, and the admissions director received education on appropriate notification and documentation of Bed Hold policy notifications. Like residents are identified as those who have been transferred emergently from the facility. A facility sweep was completed by 4/30/2025 of transferred residents from the last 2 weeks to ensure proper notification of the Bed Hold policy was provided and documentation made in their EMR. The policy for Bed Hold has been reviewed and deemed appropriate. The Business Office Manager has been educated on appropriate processes on 4/23/2025. The QAPI Committee has directed the NHA and/or designee to ensure that weekly audits are completed on 100% of residents who are transferred out emergently to ensure the proper process is followed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.