Failure to Provide Bed-Hold Policy Notification and Discharge Recapitulation
Penalty
Summary
The facility failed to provide a resident with written information regarding the bed-hold policy when the resident was transferred to the hospital. The resident in question had multiple diagnoses, including congestive heart failure, edema, GERD, and anxiety, and was noted to have moderately impaired cognition and required staff assistance with activities of daily living. During an acute episode involving fever and respiratory distress, the resident was transferred to the hospital, but the clinical record did not contain documentation that the bed-hold policy was provided to the resident or their representative, as required by facility policy. Administrative staff confirmed that there was no evidence of a signed bed-hold policy being given or acknowledged at the time of transfer. Additionally, the facility failed to complete a required recapitulation as part of the comprehensive discharge summary for another resident who was discharged home. This resident had a history of a femur fracture, anxiety, major depressive disorder, and hypertension, and required significant staff assistance with daily care. The care plan included arrangements for community resources and home health services upon discharge. However, review of the electronic medical record revealed that a discharge summary, including a recapitulation of the resident's stay, was not completed as required by facility policy. Administrative staff were unable to locate the required documentation. Both deficiencies were identified through record review and staff interviews, which confirmed the absence of required documentation and notifications related to resident needs, appeal rights, and bed-hold policies. The facility's own policies specify the need for written information and documentation in these situations, but these procedures were not followed in the cases reviewed.