§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
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Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to obtain a physician's order for a discharge and make certain that the necessary resident information was communicated to the receiving health care provider for one out of five residents sampled with facility-initiated transfers (Resident R1).
Findings include:
Review of facility policy "Documentation of Resident Discharge" dated 2/1/24, indicated that documentation will be completed when a resident is discharged form this facility. The following items are to be documented when a resident is discharged from the facility to home or another facility:
- Resident current condition, including mental status
- Physician's discharge order has been obtained
- Transfer form, facesheet, history, and physical
- Physician current orders and completed testing
Review of the clinical record indicated Resident R1 was admitted to the facility on 7/18/24.
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/5/24, indicated diagnoses of high blood pressure, muscle spasms, and multiple sclerosis (a disease that affects central nervous system).
During a review of the clinical record indicated Resident R1 was transferred to an Inpatient Rehabilitation Center on 7/25/24.
During a review of Resident R1's clinical record on 7/31/24, at 12:05 p.m. failed to reveal a physician order for discharge to an inpatient rehabilitation center on 7/25/24.
During a review of Resident R1's clinical record on 7/31/24, at 12:10 p.m. revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
During an interview on 7/31/24, at 1:05 p.m. Social Worker Employee E1 stated "I faxed all the information but did not document anything".
During an interview on 7/31/24, at 2:10 p.m. Director of Nursing confirmed that the facility failed to obtain a physician's order for a discharge and make certain that the necessary resident information was communicated to the receiving health care provider for one out of five residents sampled with facility-initiated transfers (Resident R1).
28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.
| | Plan of Correction - To be completed: 08/23/2024
The Facility cannot retroactively correct the errors found for Resident R1.
Facility confirmed with Rehab facility no additional information was needed regarding discharge of Resident R1.
The Director of Nursing, or designee, will educate all Licensed Staff regarding discharge process and obtaining physician orders.
The Director of Nursing will complete audits weekly for 4 weeks and then monthly for 3 months to ensure physician orders are obtained at discharge and all necessary information was communicated to receiving health care facility at transfer.
The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
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