|§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.
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.
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for two out of 19 sampled residents who were transferred to the hospital (Residents 74 and 36).
The findings include:
A review of the Resident 74's clinical record revealed that the resident was transferred from the facility and admitted to the hospital on April 6, 2022. The resident returned to the facility on April 11, 2022. The resident was transferred from the facility again on April 25, 2022, and returned to the facility on April 28, 2022.
A review of Resident 36's clinical record revealed the resident was transferred from the facility and admitted to the hospital on March 13, 2022. The resident returned to the facility on March 14, 2022. The resident was transferred from the facility to the hospital again on March 17, 2022, and returned to the facility on March 21, 2022.
There was no documented evidence that the facility had provided the necessary resident information to the receiving health care facility regarding these residents (If the resident is being transferred, and return is expected, the following information must be conveyed to the receiving provider: Contact information of the practitioner who was responsible for the care of the resident; Resident representative information, including contact information; Advance directive information; Special instructions and/or precautions for ongoing care, as appropriate, resident's comprehensive care plan goals; and all information necessary to meet the resident's needs. this information must be conveyed as close as possible to the actual time of transfer).
Interview conducted on May 19, 2022, at 10:40 AM with the Director of Nursing (DON) stated the information communicated to the receiving health care facility upon transfer or discharge from the facility is documented in a progress note, however, the documentation could not be found at the time of the survey ending May 20, 2022
28 Pa. Code 201.29(f) Resident rights
| ||Plan of Correction - To be completed: 06/16/2022|
1. R36 returned from the hospital on 3/21/22 and R74 returned from the hospital on 4/28/22.
2. Residents that were transferred from the facility to the hospital in the last 30 days will be reviewed to ensure that the receiving health care facility has received the required documentation related to the resident. Follow up will be completed based on findings
3. Re-Education was provided to the licensed staff related to documentation of information communicated to the receiving health care facility upon transfer or discharge from the facility.
4. Quality review of nursing documentation will be completed by the DON or designee to ensure documentation related to information communicated to the receiving health care facility upon transfer or discharge from the facility is documented in the medical record and will occur 5x/week for 8 weeks. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.