§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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for four of eight residents reviewed for hospitalization (Residents R1, R56, R58, and Closed Record Resident CR149).
Findings include:
Review of a facility policy entitled "Transfer or Discharge, Facility Initiated," dated January 2026, indicated that should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: basis for the transfer or discharge, contact information of the practitioner responsible for the care of the resident, resident representative information, advance directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other information necessary to meet the resident's needs.
Resident R1's clinical record revealed an admission date of 2/18/25, with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time), pneumonia (inflammation and fluid in your lungs caused by bacteria, viral, or fungal infection causing symptoms such as cough, chills, fever, and difficulty breathing), and high blood pressure.
Resident R1's clinical record revealed a progress note dated 10/17/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider.
Resident R56's clinical record revealed an admission date of 5/10/18, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), pleural effusion (buildup of excess fluid between the layers of the pleura outside your lungs), and dementia (loss of cognitive functioning affecting a person's memory and behaviors).
Resident R56's clinical record revealed a progress note dated 12/4/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider.
Resident R58's clinical record revealed an admission date of 2/26/21, with diagnoses that included anemia (a reduction in red blood cells resulting in symptoms such as fatigue and weakness), gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and blindness in right and left eye.
Resident R58's clinical record revealed a progress note dated 10/7/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider.
Resident CR149's clinical record revealed an admission date of 8/12/25, with diagnoses that included extradural and subdural abscess (serious infections that occur in the spaces surrounding the brain and spinal cord), Chronic Obstructive Pulmonary Disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing), and Atrial Fibrillation (A-Fib irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications).
Resident CR149's clinical record revealed a physician order dated 8/18/25, indicating to send Resident CR149 to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider.
During an interview on 1/22/26, at 2:09 p.m. Director of Nursing confirmed that Residents R1, R56, R58, and CR149's clinical records lacked evidence that necessary clinical information was communicated to the receiving health care provider.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(c.3)(2) Resident rights
| | Plan of Correction - To be completed: 03/16/2026
After review of R1, R56, R58 and CR149. No negative outcomes came as a result of missing clinical information.
A 2-week look back on all hospital ER transfers was completed for accurate and detailed clinical information provided to receiving facility.
Based on the transfer look back it was determined that the Director of Nursing will provide RN/LPN staff education on the Transfer or Discharge policy. A transfer "cheat sheet" will be created and kept on each unit laying out the information that needs to be communicated to the receiving facility. LPN/RN staff education will be provided on the purpose of the transfer "cheat sheet".
The Director of Nursing or designee will audit all hospital ER transfer progress notes ensuring that accurate and detailed clinical information is being relayed to the accepting facility to ensure continuity of care. These audits will be daily x 2 weeks, weekly x 2 weeks, and then periodically thereafter.
Results of audits will be reviewed at Quality Assurance Performance Improvement.
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