|§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 a review of the clinical record of a resident whose discharge was initiated by the facility and select facility incident/accident reports, and staff interview, it was revealed that the facility failed to assure the presence of required documentation in the resident's medical record of the necessity of pursing a resident's discharge for one (resident CR1) out of two discharged residents reviewed.
A review of the clinical record revealed that Resident CR1 was admitted to the facility on October 21, 2021, with diagnoses, which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).
Review of Resident CR1's admission nursing assessment dated October 21, 2021, which included an elopement risk assessment, indicated that the resident was ambulatory and at risk for elopement [the total score (low risk score 0-4; moderate risk score 5-10; high risk score 11 plus) of the elopement risk was not calculated].
Review of a facility incident/accident report dated October 26, 2021, at 6:30 AM revealed that Resident CR1 eloped through the window in her room. The location of the resident's room and window directly faced the highway and industrial park where a hotel was located (an approximate 0.3 mile distance, an approximate 6-minute walk from the facility).
A late entry nurses note dated October 26, 2021, at 7:00 AM, entered by Employee 1, the RN supervisor dayshift 7:00AM to 3:00 PM, on October 26, 2021 at 12:00 PM, indicated that Resident CR1 was not in the facility. The director of nursing was notified. The resident was picked up at the police barracks and returned to the facility. Window were screwed closed to prevent further escapes. The responsible party was notified. A skin check was completed, and no injuries were noted to the resident. Resident checked frequently.
Review of a statement by the administrator dated, October 26, 2021, at 8:30 AM revealed that Resident CR1 relayed to the facility staff that she took a folding chair (kept in the room for staff/visitors to use) from her closet, put the chair next to the window, unfolded the chair, and climbed out the window. The resident demonstrated how she was able to unsecure child proof window locking mechanisms to disengage the lock. The resident noted that after she climbed out the window and closed the window and screen most of the way so that they wouldn't know that she left. The resident stated that she walked across the street at the traffic light and went to the hotel across the road to call a cab to take back to the city where she lived prior to being admitted. The statement noted a social work referral was placed for follow-up to transfer the resident to a secured unit with a wanderguard system (doors lock and alarm when someone wearing a wanderguard bracelet approaches).
A social services note dated October 26, 2021, at 10:34 AM indicated that the facility contacted 10 local nursing homes looking for a locked unit for the resident. The social service note indicated the facility was awaiting call back, noting that either no beds were available, or they do not have a locked unit. The social service note indicated "Will keep attempting."
A social services note dated October 28, 2021 at 3:37 PM noted the responsible party okayed the resident's transfer to another facility tomorrow, which was a sister facility located approximately two hours from this current facility.
A nurses note dated October 29, 2021 at 10:35 AM noted the resident was aware of planned transfer to another facility.
A nurses note dated November 2, 2021 at 9:33 AM noted the resident aware of transfer later today. The entry noted that the resident was "Expressing feelings of sadness, emotional support offered. Message left for responsible party regarding transfer today. Continue to check on resident."
A nurses note dated November 2, 2021 at 1:35 PM noted the resident was transferred to another facility via medical transport. The resident was tearful upon reviewing discharge instructions, emotional support given. Medications and all belongings sent with the resident.
Further review of the clinical record revealed there was no documentation in the resident's clinical record from the facility's interdisciplinary team and the resident's attending physician regarding the specific needs that could not be met in this skilled nursing facility to demonstrate the necessity of the resident's transfer to another skilled nursing facility for the resident's welfare.
Interview with the nursing home administrator (NHA) on November 9, 2021 at approximately 2:00 PM revealed the resident was discharged to another facility, which had a wanderguard system (doors lock and alarm sounds when someone wearing a wanderguard bracelet approaches). The NHA confirmed that adequate staff supervision is to be provided at the facility for all residents including residents at risk for elopement to ensure resident safety. The NHA verified that the facility failed to provide required documentation in the resident's clinical record from the facility's interdisciplinary team and the resident's attending physician regarding the specific needs that could not be met to demonstrate the necessity of the resident's transfer for the resident's welfare.
Refer to F689
28 Pa. Code 211.12(a) Physician's Services.
28 Pa. Code 211.5 (f)(g)(h) Clinical Records.
28 Pa. Code 201.29(f)(g) Resident Rights.
| ||Plan of Correction - To be completed: 12/03/2021|
1. Resident CR1's RP asked for a transfer to a facility that was equipped with a Wander Guard system.
2. There were no other residents impacted by this deficient practice.
3. The SW was re-educated on the required documentation (including MD note) in the resident's clinical record regarding the specific needs that could not be met by the facility. The NHA will conduct a review of scheduled discharges for appropriateness.
4. The NHA or designee will conduct an audit of discharged residents weekly x 4 weeks then monthly x 2 months to ensure appropriate documentation is present in the medical record. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.