Deficiency in Bed-Hold Notice Provision
Summary
The facility failed to provide the required bed-hold notices upon transfer or discharge for several residents, as evidenced by clinical record reviews and staff interviews. Specifically, two residents did not receive a copy of the facility's bed-hold notice upon transfer or discharge, and five residents received notices that lacked necessary information. The missing information included the duration of the state bed-hold policy and the reserve bed payment policy, which are required by regulations. Resident 1, who had diagnoses including heart failure and chronic kidney disease, was transferred to the hospital, but the bed-hold notice provided did not include the required information about the state bed-hold duration or reserve bed payment. Similarly, Resident 28, with diagnoses of heart failure and dementia, was transferred multiple times without receiving complete bed-hold notices. In one instance, the facility failed to provide any bed-hold notice at all. Staff interviews confirmed these omissions and acknowledged the failure to include necessary details in the notices. Additional residents, including Residents 52, 53, 58, and 69, also experienced similar deficiencies. Resident 52, with hypertension and diabetes, was transferred to the hospital, but the notice lacked information on the state bed-hold duration and reserve payment. Resident 53, who suffered a fall, did not receive a bed-hold policy notice upon transfer. Resident 58 and Resident 69 also received incomplete notices, missing critical information about the bed-hold policy. Staff interviews further confirmed these deficiencies, highlighting a systemic issue in the facility's handling of bed-hold notices.
Plan Of Correction
1. Unable to retroactively correct the clinical record for R28 and R53 to provide clinical record of the facility's bed-hold notice upon date of transfer or discharge from the facility. Both residents continue to reside at the facility. Unable to retroactively correct the clinical record for R1, R28, R52, R58 and R69 to provide bed-hold notices that included the required information upon transfer; residents continue to reside at the facility. R69 no longer resides at the facility, no adverse effects related to practice. 2. All residents have the potential to be impacted. R1, 28, 52, 53, and 58 immediately will be given the form regarding Bed Hold Notice regulation no later than March 14, 2025 or any need for bed hold notice immediately of Transitions of Care Policy and Procedure, Admission, Transfers, and Discharge for the Resident and/or Resident Representative. R69 no longer resides at the facility, no adverse effects related to practice. 3. Facility wide Audits of all bed hold transfers or discharges for the past 3 months will be conducted by the DON and/or Shift Supervisor. Any residents who do not have the appropriate information on the bed transfer form will be given a new form with the revised information by March 14, 2025. 4. The DON will in-service the Shift Supervisor upon emergent transfer to the hospital to provide the Notice of Bed Hold form to the resident by March 14, 2025. The Shift Supervisor is to then complete a progress note stating it was provided, and to whom. DON will educate the Shift Supervisors on the revised Notice of Bed Hold Form to the resident upon emergent transfer to the hospital, and document in a progress note in the EHR (PCC) System that it was given. 5. Social Worker Director and DON will conduct a record audit via the progress notes of all residents who have emergent bed-hold notices upon transfer or discharge to the hospital and audit the transfer and discharge log to be sent to the Ombudsman daily x 3 to ensure the Notice of Residents Transfer or Discharge form was given and signed appropriately, to whom until 100% completion is achieved. Audits will continue x2 weekly, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.
Penalty
Two residents who were transferred to an acute care hospital did not receive written bed hold notices, nor did their family members or legal representatives. Review of clinical records and staff interviews confirmed the absence of required documentation at the time of transfer.
Staff did not provide written bed hold policy notifications to three residents or their representatives during hospital transfers, as required by facility policy. Record reviews and resident interviews confirmed the absence of these notices, and staff interviews revealed a lack of oversight to ensure the notifications were consistently issued and documented.
Facility staff did not provide a resident and/or the resident's representative with the required written bed-hold policy notification when the resident, who had multiple serious medical conditions and moderate cognitive impairment, was transferred to a hospital. No documentation of the notification was found in the clinical record, and the DON confirmed its absence during the survey.
A resident who was recently hospitalized for shortness of breath was not provided with the required written bed-hold policy before transfer. The NHA confirmed that neither the resident nor their representative received this information, and was unaware of the requirement.
A resident was transferred to a hospital without receiving written notification of the facility's bed-hold policy, and staff confirmed that no such documentation was provided prior to the transfer.
A resident with congestive heart failure was transferred to the hospital multiple times without being provided the required written bed hold notification. Documentation was incomplete or missing for each transfer, with no evidence that the bed hold policy was communicated or acknowledged as required by regulation.
Failure to Issue Written Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, or their family members or legal representatives, when the residents were transferred to an acute care hospital. Specifically, the clinical records for both residents showed that they were transferred and subsequently admitted to a hospital, but there was no documentation that a written bed hold notice was issued at the time of transfer. This was confirmed during an interview with the Market Clinical Advisor, who was unable to locate any evidence of the required notification in the records for either resident. The deficiency centers on the lack of written communication regarding bed hold policy to the residents or their representatives at the time of hospital transfer, as required by regulation.
Failure to Provide Bed Hold Policy Notification at Hospital Transfer
Penalty
Summary
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to the hospital for three out of four sampled residents. According to the facility's own Bed Hold Policy Guidelines, notification is required upon admission, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. Record review showed that for three residents, there was no documentation that a bed hold notice was issued during multiple hospital discharges and readmissions. Interviews with the residents confirmed that they did not receive a bed hold notice at the time of their transfers. Further interviews with facility staff, including the ADON, SSD, DON, and the administrator, revealed that the responsibility for issuing and filing the bed hold notice lies with the charge nurse, with follow-up by the SSD. However, staff were unaware that some notices had not been issued, and there was no clear process to double-check that the notices were consistently provided and documented. The facility census at the time was 88.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
Facility staff failed to provide a resident and/or the resident's representative with the facility's bed-hold policy upon the resident's transfer to a higher level of care. Specifically, for one sampled resident with multiple significant diagnoses, including heart failure, chronic respiratory failure, and cognitive impairment, there was no documented evidence that the required written notification regarding the bed-hold policy was given at the time of transfer to the hospital. A review of the clinical record confirmed the absence of this documentation, and the DON was unable to locate any evidence that the bed-hold policy had been provided. This deficiency was identified through staff interviews, clinical record review, and facility document review, and was discussed with facility leadership during the survey process.
Failure to Provide Bed-Hold Policy Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold policy to a resident or the resident’s representative prior to the resident’s transfer to the hospital. During an interview, the resident confirmed a recent hospitalization and review of the resident’s progress notes documented the transfer for further evaluation of shortness of breath. Subsequent interviews with the Nursing Home Administrator revealed that neither the resident nor their representative received the required bed-hold policy information before the transfer, and the administrator was unaware of the requirement to provide this policy.
Failure to Provide Written Bed-Hold Policy Notification Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to a resident or the resident’s representative prior to the resident’s transfer to a hospital. Medical record review showed that, before the resident was transferred in August 2024, there was no documentation indicating that the required written notification was given. Staff interviews confirmed that neither the resident nor the representative received the facility’s bed-hold policy paperwork or documentation before the transfer occurred.
Failure to Provide Bed Hold Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide proper bed hold notification to a resident who was transferred to the hospital on three separate occasions. Documentation review showed that the required written notice regarding the bed hold policy was not present in the resident's chart for any of the transfers. Specifically, there was no evidence of a completed bed hold notification form, no date or time of notification, no name of the person who provided the notification, and no indication of whether the bed hold was accepted or declined. Additionally, there was no signature from the resident or their representative to confirm that the notification was given. The resident involved had a diagnosis of congestive heart failure and was admitted to the facility in 2025. The resident was transferred to the hospital on three occasions, but in each instance, the facility did not provide the required written information about the bed hold policy as outlined in their own policy and federal regulations. Interviews with medical records staff confirmed the absence of proper documentation and notification for each transfer event.
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