§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).
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Observations:
Based on clinical record review, it was determined that the facility failed to notify the residents and the residents' representatives regardless of transfers from the facility and reasons for the moves in writing for six of nine sampled residents who were transferred to the hospital. (Residents 19, 28, 32, 79, 81, 123)
Findings include:
Clinical record review revealed that Resident 19 was transferred and admitted to the hospital on December 14, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 28 was transferred and admitted to the hospital on September 12, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 32 was transferred and admitted to the hospital on November 9, 2023, and January 1, 2024, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 79 was transferred and admitted to the hospital on October 4, 2023, and December 20, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident' transfer to the hospital.
Clinical record review revealed that Resident 81 was transferred and admitted to the hospital on October 3, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 123 was transferred and admitted to the hospital on October 27, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.
In an interview on January 24, 2024, at 12:54 p.m., the Administrator confirmed that written transfer information, including the reasons for the move, was not provided to the residents and the residents' representatives.
| | Plan of Correction - To be completed: 03/06/2024
This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law.
1. Facility cannot retroactively correct the omission of the missing Notice of Transfer forms for the Six residents identified. 2. Education was provided for the nursing staff on the use of the Notice of Transfer form for any resident being transferred to an acute care setting. 3. Moving forward, any Notice of Transfer forms that are completed by the nursing staff, the original will be sent with the resident and a copy will be sent to administration for review and forwarded to the RP by mail. 4. Residents that are transferred to an acute care setting will be reviewed in morning clinical meeting to ensure the Notice of Transfer form was sent with the resident. Weekly summaries will be done and reviewed with the Director of Nursing and RN Unit Manager for three months. Results of the weekly audit will be reported to the QA meeting for three months for review.
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