§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.
(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.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.
§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.
§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.
§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
§483.15(d) Notice of bed-hold policy and return-
§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.
§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
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Observations:
Based on a review of facility policy and documents, information provided by the State Ombudsman Office, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of six residents reviewed for hospitalization (Resident R6, R89, R123, and R138) and failed to notify the State Ombudsman Office of resident transfers and discharges for two years (11/2023 through 12/2023, 1/2024 through 12/2024, and 1/2025 through 4/2025) as required.
Findings Include:
Review of federal regulation Notice of Bed-Hold Policy, indicated:
-Facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies.
-The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility ' s policy were to change.
-The second notice must be provided to the resident, and if applicable the resident ' s representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident ' s representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed.
Review of facility "Bed Hold Policy" dated 3/4/25, indicated, "In accordance with federal and state guidelines, patients who are hospitalized or absent from the facility at midnight are entitled to hold their bed."
Review of the clinical record indicated Resident R6 was readmitted to the facility on 1/1/25.
Review of Resident R6's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/28/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), anxiety, and depression. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "03."
Review of a progress note dated 3/16/25, at 3:32 a.m. indicated, "CNA (nurse aide) heard noise come from resident's room, found her sitting on the floor up against her bed, feet out in front of her, shoes on, bleeding from hematoma on right forehead. Pressure dressing applied, Ice pack to right side of face/forehead. Observed large hematoma, bubbled, and draining profusely. LOC (level of consciousness) WNL (within normal limits), resident stated I fell right there, I need to go to the hospital." "Left facility enroute to [hospital emergency room] at 3:15 a.m."
Further review of Resident R6's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R6 or the resident representative upon transfer.
Review of the clinical record indicated Resident R89 was admitted to the facility on 4/10/20.
Review of Resident R89's MDS dated 4/1/25, included diagnoses Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior) and high blood pressure. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "99," meaning that Resident R89 was so cognitively impaired to be unable to complete the interview. Review of a previous MDS assessment dated 10/17/24, also revealed a BIMS score of "99."
Review of a progress note dated 12/23/24, at 2:51 p.m. indicated, "Residents son, [second emergency contact] was informed [Resident R89] has been admitted to [hospital] with a dx of UTI (urinary tract infection)."
Further review of Resident 89's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident R89 or the resident representative upon transfer.
Review of the clinical record indicated Resident R123 was readmitted to the facility on 1/1/25.
Review of Resident R123's MDS dated 5/5/25, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and cancer. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "99," meaning that Resident R89 was so cognitively impaired to be unable to complete the interview.
Review of a progress note dated 12/26/24, at 1:13 p.m. indicted, "Alerted by staff that pt (patient) was off her baseline. Pt assessed and found lying in bed. Lethargic and barely arousable. Per staff, pt is usually OOB (out of bed) and at the nurse ' s station at this time." "MD (doctor of medicine) notified and ordered pt sent to ER (emergency room) for eval."
Review of a progress note dated 1/1/25, at 7:34 p.m. indicated, "Pt is admitted from [hospital] with diagnosis of RSV (Respiratory syncytial virus, causes infections of the respiratory tract).
Further review of Resident 123's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R123 or the resident representative upon transfer.
Review of the clinical record indicated Resident R138 was admitted to the facility on 2/3/25.
Review of Resident R138's MDS dated 2/10/25, included diagnoses of falls, ileus (inability of the intestine (bowel) to contract normally and move waste out of the body), and muscle wasting. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "07."
Review of a progress note dated 2/8/25, at 1:00 a.m. Pt's nurse went to give her scheduled Tylenol 1000 mg in her bedroom, patient pushed nurse in her right breast away and into tv stand, patient became belligerent, cursing at staff, appears paranoid, making statements that she is going to call the police on staff, she is going to kill staff, staff is trying to kill her, patient stated she was going to have staff buried with her, aggressive, yelling a loud on dementia unit, RN registered nurse supervisor (RNS) was called up to unit, [RNS] and [nurse aide] were trying to redirect her/talk to her, unsuccessful, her daughter was called/put on speaker-patient refused to speak with her, supervisor explained above situation to daughter, daughter explained patient has had 3 alcoholic drinks or more a day prior to coming here, patient picked up a large/heavy pill crusher tried to throw it at me and [nurse aide], tried to hit us with it, we were able to take it away from her however she picked up the laptop and tried to use that to hit us, received permission from daughter to send out for evaluation, police officer arrived and [emergency services]came to pick her up, patient went with them willingly to [hospital] for evaluation."
Further review of Resident 138's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R138 or the resident representative upon transfer.
A request to review facility documents on 5/14/25, of the facility's compliance in notifying the State Ombudsman Office revealed the facility failed to provide documented evidence of notifying the State Ombudsman Office of resident transfers and discharges for the time period of 11/2023 through 4/2025.
A review of information on 1/2/25, provided by the State Ombudsman Office revealed that the facility failed to notify the State Ombudsman Office of transfers and discharges as required since 11/2023.
During an interview on 5/15/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of six residents reviewed for hospitalization and failed to report resident transfers and discharges to the State Ombudsman Office for a two year period from 11/2023 through 4/2025, as required.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa Code: 201.29(f)(g) Resident rights.
| | Plan of Correction - To be completed: 06/10/2025
For Residents R6, R89, R123, and R138, retrospective written notification of the bed-hold policy was issued to the residents' representatives, accompanied by an explanation and apology for the oversight. All resident records were updated to reflect this communication. No adverse outcomes were reported as a result of the missing documentation. For the failure to notify the State Ombudsman Office, the facility submitted a backlog of required notifications covering November 2023 through April 2025 to the Ombudsman Office on May 16, 2025.
A facility-wide audit was conducted for all residents transferred or discharged between January 1 and May 15, 2025, to verify issuance of bed-hold notices and Ombudsman notifications. Any missing notifications will be issued retroactively.
The administrator will educate nursing staff and business office employees on obtaining written notification of the bed-hold policy on transfer. The regional director of nursing will educate social services on proper monthly state ombudsman notification for transfers.
The business office director or designee will audit notification of bed hold policy 2 times a week for four weeks, weekly for two weeks, then determined by QAPI thereafter. The Social Services Director or designee will maintain a submission log for all Ombudsman notifications and submit monthly compliance reports to the Administrator and QA Committee.
All corrective actions will be completed by June 10, 2025.
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