BERLIN, PA - Federal inspectors cited Meadow View Nursing Center for failing to provide required written notices about bed-hold policies to residents and their families during hospital transfers.
Facility Failed to Follow Federal Notification Requirements
A February 2025 inspection revealed that Meadow View Nursing Center violated federal regulations by not providing written bed-hold notices to three residents who were transferred to hospitals. The citations affected residents who experienced falls resulting in serious injuries, including ankle and hip fractures.
The violations occurred between October and November 2024, involving residents with varying levels of cognitive impairment and complex medical conditions. Federal regulations require nursing homes to inform residents and their representatives in writing about how long the facility will hold their bed during hospital stays or therapeutic leave.
Three Documented Cases of Missing Notifications
Resident 3 - Ankle Fracture After Fall On November 19, 2024, a resident with moderate cognitive impairment fell in her room and sustained an obvious left ankle deformity. The injury was later diagnosed as a displaced trimalleolar fracture of the left lower leg, which affects the ankle joint. Despite being transferred to the emergency room for evaluation and treatment, no bed-hold notice was provided to the resident or her responsible party.
Resident 45 - Hip Fracture Emergency A cognitively intact resident with multiple health conditions including atrial fibrillation, high blood pressure, and chronic obstructive pulmonary disease fell on November 14, 2024. Nursing staff documented that the resident's right leg was shortened and externally rotated, indicating a serious hip injury. The resident was transported to the local hospital, but facility staff failed to provide the required bed-hold notification to the resident's representative.
Resident 93 - Hospital Transfer with Complex Wounds A resident with cognitive impairment, diabetes, and peripheral vascular disease was transferred to the hospital on October 4, 2024. This resident had multiple serious conditions including an unstageable pressure ulcer and venous ulcer, both requiring specialized medical attention. No bed-hold notice was documented for this resident's representative.
Medical Significance of Bed-Hold Policies
Bed-hold policies serve critical functions in nursing home operations and resident care continuity. When residents are transferred to hospitals for medical emergencies, families need clear information about how long the nursing home will reserve their bed and what financial obligations may continue during the hospital stay.
For residents with cognitive impairment, this information becomes even more crucial as family members or responsible parties must make informed decisions about care arrangements. The lack of proper notification can create uncertainty about housing arrangements and financial responsibilities during what is often an already stressful medical crisis.
Trimalleolar fractures, like the one experienced by Resident 3, typically require surgical intervention and extended rehabilitation. Hip fractures, such as the injury sustained by Resident 45, are among the most serious fall-related injuries in elderly populations and often require lengthy hospital stays followed by intensive rehabilitation.
Facility's Response and Corrective Actions
The nursing home administrator confirmed during a February 4, 2025 interview that the facility had failed to provide bed-hold notices to the affected residents and their representatives. The administrator revealed that facility management had identified this compliance issue on November 24, 2024.
Following this internal discovery, Meadow View implemented several corrective measures:
- Staff education regarding required bed-hold notice procedures was provided - Regular audits of all hospital transfers were initiated - Results from these audits were designated for review by the Quality Assurance Performance Improvement committee
The facility's proactive identification of the problem and implementation of systematic corrections demonstrated acknowledgment of the regulatory violation and commitment to compliance improvement.
Regulatory Requirements and Industry Standards
Federal regulations under the Nursing Home Reform Act require facilities to provide written notification about bed-hold policies when residents are transferred to hospitals or take therapeutic leave. This requirement ensures transparency in facility policies and helps families understand their options during medical emergencies.
The notification must clearly explain how many days the facility will hold the resident's bed, any associated costs, and the resident's rights regarding readmission. These policies vary by facility and may depend on the resident's payment source, such as Medicare, Medicaid, or private insurance.
Industry best practices recommend that bed-hold notices be provided immediately upon transfer or as soon as practical thereafter. The written notice should be given to the resident if they are capable of understanding, or to their designated representative if the resident has cognitive impairment or is unable to comprehend the information due to their medical condition.
Implications for Resident Rights and Family Planning
The absence of proper bed-hold notifications can significantly impact families' ability to make informed decisions during medical crises. When a nursing home resident is hospitalized, families need to understand whether the facility will reserve the resident's room and for how long.
Without this information, families may face uncertainty about where their loved one will live after hospital discharge. This is particularly challenging for residents with complex medical needs who require specialized nursing home care, as alternative placement options may be limited.
The financial implications are equally important. Some facilities continue charging private-pay residents during hospital stays, while others may not hold beds beyond a certain timeframe. Clear communication about these policies allows families to plan accordingly and understand their financial obligations.
Broader Context of Nursing Home Compliance
This citation represents part of ongoing federal oversight of nursing home operations nationwide. The Centers for Medicare & Medicaid Services conducts regular inspections to ensure facilities meet federal standards for resident care, safety, and rights protection.
While the violations at Meadow View were classified as causing minimal harm with potential for actual harm, they highlight the importance of administrative compliance in protecting resident rights. Even procedural violations can have meaningful impacts on residents and families navigating complex healthcare decisions.
The facility's self-identification of the problem and implementation of corrective measures before the federal inspection demonstrates internal quality monitoring systems, though it also reveals that the violations occurred over several months before being addressed.
Families considering nursing home placement should inquire about bed-hold policies during the admission process and ensure they understand the facility's procedures for notification during emergencies. This information should be clearly documented in admission agreements and provided in writing as required by federal regulations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadow View Nursing Center from 2025-02-07 including all violations, facility responses, and corrective action plans.
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