§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).
|
Observations:
Based on a review of facility policy, clinical record reviews, and staff interview, 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 five of six residents reviewed for hospitalization (Resident R10, R30, R61, R99, and R114).
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 and Return Notification" dated 3/3/25, previously reviewed 11/1/24, indicated, "You will receive a copy of this agreement upon admission, upon transfer or therapeutic leave, and if any changes are made to the state or facility policies regarding this matter."
Review of the clinical record indicated Resident R10 was admitted/readmitted to the facility on 3/12/25.
Review of Resident R10's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/5/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and history of a stroke.
Review of a progress note dated 8/26/24, at 8:13 p.m. indicated, "New order obtained by [Nurse Practitioner] to have resident evaluated by [hospital emergency department] for exacerbation of UTI (urinary tract infection, infection in any part of the kidneys, bladder or urethra) symptoms, with increased agitation, physical aggression." Review of resident census information revealed Resident R10 was admitted to the hospital from 8/26/24, through 9/6/24.
Further review of Resident R10's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R10 or the resident representative upon transfer to the hospital.
Review of a progress note dated 9/7/24, at 10:09 p.m. indicated that Resident R10 was transferred to the hospital for abnormal vital signs. Review of resident census information revealed Resident R10 was admitted to the hospital from 9/7/24, through 9/13/24.
Further review of Resident R10's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R10 or the resident representative upon transfer to the hospital.
Review of a progress note dated 10/14/24, at 8:27 a.m. indicated that Resident R10 was transferred to the hospital for a fever. Review of resident census information revealed Resident R10 was admitted to the hospital from 10/14/24, through 10/19/24.
Further review of Resident R10's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R10 or the resident representative upon transfer to the hospital.
Review of the clinical record indicated Resident R30 was admitted/readmitted to the facility on 3/14/25.
Review of Resident R30's MDS dated 3/21/25, included diagnoses diabetes, heart failure (a progressive heart disease that affects pumping action of the heart muscles) and a seizure disorder.
Review of a progress note dated 12/24/24, at 4:31 p.m. indicated that Resident R30 was transferred to the hospital for further evaluation. Review of resident census information revealed Resident R30 was admitted to the hospital from 12/24/24, through 1/2/25.
Further review of Resident R30's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R30 or the resident representative upon transfer to the hospital.
Review of the clinical record indicated Resident R61 was admitted/readmitted to the facility on 10/20/24.
Review of Resident R61's MDS dated 5/9/25, included diagnoses of cardiomyopathy (disease of the heart muscle), high blood pressure, and chronic kidney disease (gradual loss of kidney function).
Review of a progress note dated 9/13/24, at 2:50 p.m. indicated that Resident R61's dialysis port and dressing wer red and warm to touch, and that Resident R61 went to dialysis and the nephrologist (medical doctor specializing in kidney care) wanted her sent to the emergency room. Review of resident census information revealed Resident R61 was admitted to the hospital from 9/13/24, through 9/23/24.
Further review of Resident R61's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R61 or the resident representative upon transfer to the hospital.
Review of a progress note dated 10/18/24, at 9:17 a.m. indicated that Resident R61 was sent to the hospital related to a dialysis port infection. Review of resident census information revealed Resident R61 was admitted to the hospital from 10/18/24, through 10/22/24.
Further review of Resident R61's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R61 or the resident representative upon transfer to the hospital.
Review of the clinical record indicated Resident R99 was admitted/readmitted to the facility on 12/10/24.
Review of Resident R99's MDS dated 2/10/25, included diagnoses of coronary artery disease, high blood pressure, and pneumonia (infection that inflames the air sacs in one or both lungs).
Review of a progress note dated 12/8/24, at 11:58 p.m. indicated that Resident R99 experienced chest pain and was transferred to the emergency room. Review of resident census information revealed Resident R99 was admitted to the hospital from 12/8/24, through 12/10/24.
Further review of Resident R99's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R99 or the resident representative upon transfer to the hospital.
Review of a progress note dated 2/24/25, at 10:24 p.m. indicated that Resident R99 experienced chest pain and was transferred to the emergency room. Review of resident census information revealed Resident R99 was admitted to the hospital from 2/24/25, through 3/1/25.
Further review of Resident R99's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R99 or the resident representative upon transfer to the hospital.
Review of the clinical record indicated Resident R114 was admitted/readmitted to the facility on 5/6/25.
Review of Resident R114's MDS dated 2/10/25, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), hemiplegia (paralysis on one side of the body), and malnutrition (lack of sufficient nutrients in the body).
Review of a progress note dated 2/15/25, at 11:45 a.m. indicated that Resident R114 had a swollen tongue and was unable to speak or swallow. Resident R114 was transferred to the emergency room. Review of resident census information revealed Resident R114 was admitted to the hospital from 2/15/25, through 2/22/25.
Further review of Resident 114's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R114 or the resident representative upon transfer to the hospital.
During an interview on 5/23/25, at approximately 12:45 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 five of six residents reviewed for hospitalization.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa Code: 201.29(f)(g) Resident rights.
| | Plan of Correction - To be completed: 06/18/2025
It is the facility's policy to provide written bed-hold notification to residents and/or their representatives at the time of transfer to the hospital, in accordance with F483.15(d).
Corrective Action for Affected Residents: On 5/23/25, the Director of Nursing reviewed the medical records of Residents R10, R30, R61, R99, and R114. Written bed-hold notifications were provided to these residents and/or their representatives, documenting the facility's bed-hold policy and duration.
Identifying other Residents having the Potential to be Affected: On 5/24/25, the Director of Nursing conducted an audit of all residents transferred to the hospital within the past 90 days to identify any additional residents affected by this practice. Any identified residents without proper bed-hold documentation received written notification of the facility's bed-hold policy.
Measures put into place or Systemic Changes: 1. The DON will in-service all Licensed nurses by 06/18/2025 on: - Proper documentation of bed-hold notification - Requirements for providing written bed-hold notice upon transfer - Location of bed-hold forms in the facility - Process for documenting bed-hold notification in the medical record
The facility's transfer checklist has been updated to include bed-hold notification as a required step.
A new bed-hold notification tracking log has been implemented at each nurses' station.
Plan to Monitor Performance: 1. The Unit Managers and or designee will audit any hospital transfers weekly for 2 weeks to ensure bed-hold notifications are provided and documented then will be audited monthly x 1 month.
The Director of Nursing or designee will review audit results weekly and address any identified issues immediately through staff re-education or disciplinary action as needed.
The Quality Assurance Coordinator will report audit findings to the Quality Assurance Performance Improvement (QAPI) committee monthly for 1 month. The QAPI committee will evaluate the effectiveness of the interventions and make additional recommendations as needed until substantial compliance is achieved and maintained.
|
|
