Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its own policy and procedure regarding bed-holds and resident returns when a resident with complex medical needs, including a tracheostomy, was transferred to a general acute care hospital for a planned cardiology clearance. The resident, who was dependent for all activities of daily living and unable to make medical decisions or communicate, had a responsible party who requested a 7-day bed-hold at the time of transfer. Documentation confirmed that the resident and family were informed of the right to a 7-day bed-hold, and a physician's order for the bed-hold was in place. Despite these measures, the facility did not hold the resident's original sub-acute bed, which was equipped to meet the resident's specialized care needs. Instead, the facility transferred the bed-hold to a room in the skilled nursing unit that was not equipped for residents with tracheostomies. The daily census records showed the resident's name was moved from the sub-acute unit to the skilled nursing unit during the bed-hold period, and the sub-acute bed was not kept vacant for the resident's potential return. Interviews with facility staff, including the DON, confirmed that the bed-hold was not appropriately maintained in the sub-acute unit, and the new room assignment could not accommodate the resident's medical requirements. As a result, the resident was not readmitted to the facility within the 7-day bed-hold period, contrary to facility policy and the resident's rights as outlined in the bed-hold notification and informed consent documentation.