Date
of Last Review 03/24/08
SME: Associate Director of Nursing
Purpose: To define a process for the removal of patient beds from service due safety, environmental, or therapeutic reasons.
Policy:
1.0 Beds may be removed from service for clinical reasons to include, but not limited to patient safety, infection control, and the management of the therapeutic milieu. .
2.0 Beds may be removed from service for environmental reasons to include, but not limited to construction, repair, and extermination.
Clinical Process:
| 1.0 | Only medical staff, licensed nursing staff, and infection control staff may request to remove a bed from service for clinical reasons. |
| 2.0 | Removing a bed from service should be requested as a last resort. |
| 2.1 The treatment team will review and execute alternatives such as a room change, unit change, treatment plan revision as indicated. | |
| 3.0 | The request to remove a bed from service will be communicated verbally and in writing via e-mail to the Senior Nurse Manager and the Medical Director during weekdays, 8:00am-5:00pm. On week-ends and after hours, the request should be communicated to the Nursing Supervisor |
| 3.1.1 | The Senior Nurse Manger or Nursing Supervisor will validate that all available options have been exhausted, and will consult with the Director of Nursing or designee. |
|---|---|
| 3.1.2 | If required, the DON or designee will consult with the Medical Director. |
| 4.0 | In the event a bed is removed from service, the DON, designee, or /Nursing Supervisor will provide an update by e-mail every shift to Patient Registration. The e-mail will be copied to the Administrator, Medical Director, and Financial Services |
| 5.0 | Upon receipt of the bed board notification, Patient Registration Staff will change the bed status in the Patient Accounting System. |
| 6.0 | The Senior Nurse Manger or Nursing Supervisor will review the need to continue to have the bed removed from service a minimal of every shift. |
| 7.0 | The DON, designee, Nursing Supervisor, or Senior Nurse Manager will notify Patient Registration staff verbally and via e-mail when bed is returned to service. |
Environmental Process:
| 1.0 | The Director of Facilities Management or designee will notify the Administrator of the need to remove a bed from service, as well as the anticipated timeframe. |
| 2.0 | The Director of Facilities Management or designee will notify the Director of Nursing or designee, as well as the Senior Nurse Manager or / Nursing Supervisor. |
| 2.1 The Senior Nurse Manager or Nursing Supervisor will notify the unit Staff. | |
| 3.0 | The Director of Facilities Management will notify Patient Registration staffVerbally and via e-mail of the need to remove a bed from service. The e-mail will be copied to the Administrator, Medical Director, Director of Financial Services, Director of Nursing, Nursing Supervisor, and the appropriate Senior Nurse Manager. |
| 4.0 | Director of Facilities Management will notify Patient Registration staff verbally and via e-mail when bed is returned to service. . The e-mail will be copied to the Administrator, Medical Director, Director of Financial Services, Director of Nursing, Nursing Supervisor, and the appropriate Senior Nurse Manager. |
The Joint Commission: Provision of Care, Treatment, and Services
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