Failure to Honor Bed Hold and Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure the readmission of a resident who was transferred to a general acute care hospital (GACH) for treatment of pneumonia and other medical conditions. The resident, who had severe cognitive impairment, was dependent on staff for activities of daily living and lacked decision-making capacity. After being transferred to the hospital, the facility did not honor the required 7-day bed hold, and the resident's bed was reassigned to another individual within one day of transfer. Confusion and miscommunication occurred between facility staff, the hospital, and the resident's public guardian (PG). The facility's Regional Marketer (RM) and Admission Coordinator (AC) both reported being told by hospital staff or the PG that the resident would not be returning, but the PG denied ever making such a statement. The hospital social worker reported that the facility stopped answering calls and stated the resident would not be readmitted, despite discharge orders being in place for the resident to return. The RM and AC did not verify the information with the PG or the hospital, leading to further delays and the resident remaining in the hospital beyond the necessary period. The Director of Nursing (DON) was not informed of the situation and only became aware after reviewing the census, which showed the resident's bed had been reassigned. The facility's policy required honoring a 7-day bed hold for residents transferred to the hospital, but this was not followed. The failure to coordinate and communicate effectively among facility staff, the hospital, and the PG resulted in the resident not being readmitted as required by policy, prolonging the hospital stay.