§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 clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital, to ensure that a bed-hold notice was provided to the resident's responsible party and that the ombudsman was notified of the transfer to the hospital, for three of 35 residents reviewed (Residents 9, 40, 46).
Findings include:
A quarterly minimum data set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated September 10, 2025, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included heart failure and end stage kidney disease.
A nursing note for Resident 9, dated February 2, 2025, at 11:48 a.m. revealed that the resident had increased weakness and was slow to respond at dialysis, and the resident was being sent to the emergency room. A nursing note dated July 4, 2025, at 10:06 a.m. revealed that the resident was bleeding profusely at the dialysis site and was being sent to the emergency room. A nursing note dated October 8, 2025, at 10:28 a.m. revealed that the resident's fistula site was unable to be accessed during dialysis and the resident was being sent to the emergency room. A nursing note dated November 5, 2025, at 5:43 p.m. revealed that the resident's surgical site was bleeding profusely and she was being sent to the emergency room. A nursing note dated November 24, 2025, at 3:30 a.m. revealed that the resident was having redness around her port site and was not feeling herself and was being sent to the emergency room.
There was no documented evidence that written notification of transfer to the hospital was provided to Resident 9 or the resident's representative, no documented evidence that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of her transfer to the hospital on the above dates and times as required.
Interview with the Director of Nursing on December 4, 2025, at 11:18 a.m. confirmed there was no written notification of hospital transfer provided to the resident or their representative, that a bed-hold notice was not provided to their responsible party, and that the ombudsman was not notified of the transfer to the hospital on the above dates and times as required.
An annual MDS assessment for Resident 40, dated September 15, 2025, indicated that the resident was cognitively impaired, required substantial assistance from staff for all daily care needs, and had diagnoses that included high blood pressure, high cholesterol, and dementia.
A nursing note for Resident 40, dated June 9, 2025, at 10:53 a.m., revealed that the resident was having a large amount of bleeding from his urinary catheter, and hernias and tenderness in his abdomen, and was sent to the emergency room.
There was no documented evidence that written notification of transfer to the hospital was provided to the resident's representative, no documented evidence that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of her transfer to the hospital on the above date and time as required.
A quarterly MDS assessment for Resident 46, dated October 20, 2025, revealed that the resident was cognitively impaired and required maximum assistance from staff for daily care needs.
A nursing note for Resident 46, dated July 18, 2025, at 6:25 p.m., revealed that the resident was found on the floor and was very disoriented, and was sent to the emergency room for evaluation.
There was no documented evidence that written notification of transfer to the hospital was provided to the resident's representative, no documented evidence that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of her transfer to the hospital on the above date and time as required.
Interview with the Director of Nursing on December 4, at 2:54 p.m. confirmed that for Residents 40 and 46 there was no written notification of hospital transfers provided to the resident's representative or ombudsman, and that a bed hold notice was not provided.
28 Pa. Code 201.29(j) Resident Rights.
| | Plan of Correction - To be completed: 01/22/2026
No ill effects to residents 9, 40, 46 related to failure to provide bed hold policy upon transfer to hospital to resident/residents responsible party, to ensure written bed hold notice was provided and that the ombudsman was notified of the transfer to the hospital.
An audit of November's discharges was completed by the social services director and a corrected list was sent to the ombudsman on 12/3/25.
The Director of Nursing and/or designee will perform a baseline audit of any hospital transfers that took place in the last 7 days to ensure written notification and bed hold policy were provided.
The Licensed Nursing staff will be educated on bed hold policy notification to resident/resident's responsible party upon transfer to the hospital
The social services director will be educated on completion of the written bed hold notification to the resident/resident's representative and notification of the ombudsman of transfer to the hospital.
The Director of Nursing or designee will complete random weekly audits x 4 weeks of resident hospital transfers to assure that bed hold notification to resident/ resident's Responsible Party was completed upon discharge to the hospital
The Social Services Director will complete random weekly audits x 4 weeks of hospital transfers to assure that written bed hold notification was made to resident/resident's representative and transfer is recorded for ombudsman notification.
Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective for ongoing compliance.
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