Failure to Communicate Resident Information During Transfers
Summary
The facility was found to be non-compliant with the requirements for transfer and discharge under 42 CFR Part 483, Subpart B, as well as the 28 Pa. Code, during an abbreviated survey conducted in response to complaints and an infection control survey. The deficiency was identified in the facility's failure to communicate necessary resident information to the receiving health care provider for two residents who were transferred to the hospital. This lack of communication included the omission of critical details such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information. The first resident, admitted to the facility in January 2025, had a medical history that included high blood pressure, diabetes, and cerebral infarction. This resident was transferred to the hospital shortly after admission, but the facility did not document or communicate the necessary information to the hospital, which was essential for the resident's continued care. Similarly, the second resident, admitted in October 2023, with diagnoses of depression, dementia, and Parkinson's disease, was also transferred to the hospital without the required documentation and communication of care details. During an interview, the Director of Nursing confirmed the facility's failure to ensure that the necessary information was communicated to the receiving health care provider for both residents. This oversight was a direct violation of the regulatory requirements for transfer and discharge, as it did not provide the receiving facility with the information needed to meet the residents' specific needs and ensure a safe and effective transition of care.
Plan Of Correction
1. Residents R1 returned to the facility on 1/15/25 and discharged home with family on 2/3/25, and R2 returned to the facility on 1/27/25. 2. A one-week retroactive review of all facility-initiated transfers will be followed-up by telephone to ensure that all necessary resident information was communicated to the receiving health care provider and provide any information if necessary. 3. The NHA or designee will educate all licensed nursing staff and social services staff on the necessary information requirement found at F622 for transfers to a receiving health care provider. 4. The NHA or designee will audit all facility-to-facility transfers to ensure all resident information requirements were met daily x3, then five resident facility-to-facility transfers weekly x8. Results will be reviewed through QAPI for further recommendation.
Penalty
A resident with multiple complex medical conditions was discharged while her appeal was still pending, and before all necessary home equipment and support services were in place. The facility proceeded with the discharge after determining the appeal was filed outside the 10-day window, despite having received notice of the scheduled hearing. The resident was left without essential equipment and adequate caregiver arrangements, resulting in dependence on a family member for personal care.
A resident was transferred to the hospital without their comprehensive care plan goals included in the required documentation. Both an RN/Unit Supervisor and an LPN confirmed that care plan goals were not sent with residents during transfers, and this issue was reviewed with the DON.
A resident with schizophrenia and recent elopement attempts was subject to involuntary transfer and discharge procedures initiated by facility staff without the required physician documentation or orders. The DON completed the necessary forms at the direction of corporate staff, but the forms were not signed by a physician and lacked detailed medical justification. Hospital evaluation found no immediate safety concerns, and the resident's medical record did not contain physician progress notes or orders supporting the transfer or discharge.
A resident with complex psychiatric and medical needs was transferred to a hospital for evaluation after exhibiting aggressive behavior. Despite being cleared for return, the facility did not allow the resident to come back, failed to document the basis for discharge, and did not provide the required discharge notice or summary, in violation of facility policy and regulatory requirements.
The facility failed to communicate necessary information to receiving health care providers for two residents transferred to the hospital. One resident with intellectual disabilities and dementia showed symptoms requiring hospital transfer, but the facility did not document communication of care plan goals or advanced directives. Another resident with high blood pressure and depression was also transferred without documented communication of essential information. The Nursing Home Administrator confirmed these deficiencies.
A resident with multiple medical and cognitive conditions was issued a discharge notice for non-payment, but the facility did not provide a discharge summary, plan, or adequate notification to the resident, responsible party, or ombudsman. The discharge notice lacked a specific destination, and staff interviews revealed no finalized discharge plan or proper communication, contrary to facility policy.
Discharge Executed While Appeal Pending and Without Adequate Planning
Penalty
Summary
A resident was discharged from the facility while an appeal of her discharge was still pending. The resident had received a 30-day discharge notice due to nonpayment and was informed of her right to appeal. Documentation shows that the resident filed her appeal on what the facility determined was the 11th day after notice, rather than within the 10-day window, and the facility proceeded with the discharge prior to the scheduled hearing date. Both the facility and the resident had received notice of the upcoming hearing, but the discharge was carried out before the appeal was heard. The resident had multiple complex medical conditions, including chronic hepatic failure, COPD, chronic respiratory failure, heart failure, lymphedema, morbid obesity, dysphagia, depression, and anxiety. At the time of discharge, she required significant assistance with transfers, was dependent on a sit-to-stand lift, and used a wheelchair as her primary mode of mobility. Therapy and social services notes indicated that not all necessary equipment, such as the sit-to-stand lift and upright walker, were available at her home at the time of discharge. The resident also reported not having a finalized schedule for home health services and expressed distress about being dependent on a male family member for personal care, which she found undignified and uncomfortable. Facility records and interviews confirm that the discharge was executed despite the pending appeal and without all recommended equipment and services in place. The facility's policy requires a safe, orderly, and planned discharge, including ensuring the resident's needs are met at the discharge location. The resident's care plan and therapy recommendations highlighted the need for specific equipment and support, which were not fully arranged at the time of discharge.
Failure to Send Comprehensive Care Plan Goals During Resident Transfer
Penalty
Summary
The facility failed to include the resident's comprehensive care plan goals in the required documentation during a transfer to the hospital. Record review showed that one resident was hospitalized, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that the care plan goals were not sent with the resident upon transfer. The surveyor discussed this concern with the Director of Nursing.
Failure to Obtain Required Physician Documentation for Involuntary Transfer/Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the required physician documentation was included in the medical record to support a resident's transfer and discharge rights. A resident with a history of schizophrenia and elopement behaviors was admitted to the facility and, shortly after admission, attempted to leave the facility twice. Following these incidents, facility staff initiated a Petition for Involuntary/Judicial Admission and a Notice of Involuntary Transfer or Discharge (IVD), citing the safety of individuals in the facility as the reason for the proposed transfer or discharge. However, the forms were completed by the Director of Nursing at the instruction of corporate personnel, and not by a physician. The IVD form indicated that the transfer was not an emergency, and the petition lacked detailed physician input or signature. Review of the resident's medical record and hospital documentation revealed that there were no physician orders for the involuntary psychiatric admission or for discharge. The hospital evaluation found no acute psychiatric or medical condition requiring intervention, and the petition from the facility was deemed invalid due to the lack of clear immediate safety concerns and improper completion. Additionally, the resident's electronic medical record contained no progress notes from a nurse practitioner or physician regarding the need for involuntary discharge or psychiatric admission, and behavioral monitoring documentation by CNAs was incomplete, only noting the resident as "not available." Facility policy requires physician confirmation and documentation in the medical record to support emergency transfers or discharges, as well as clear documentation of the danger posed by the resident. In this case, the required physician documentation and orders were absent, and the forms were not properly completed or signed by a physician, resulting in a failure to meet regulatory requirements for transfer and discharge rights.
Failure to Document and Notify Resident Discharge After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident was not transferred or discharged without adequate reason and proper documentation. A resident with diagnoses including dementia, paranoid schizophrenia, major depressive disorder, legal blindness, and anxiety was transferred to a hospital for a psychological evaluation following aggressive and combative behavior, including breaking a window and being combative with staff. Despite being cleared medically and psychiatrically at the hospital, the resident was not allowed to return to the facility. The facility did not document the basis for the resident's discharge, nor did it provide the required discharge summary or notice to the resident or their representative. The care plan for the resident was marked as cancelled and resolved shortly after the transfer, and there was no evidence in the records of a formal discharge process or communication of the discharge decision. Interviews with facility administration and the resident's family confirmed that the resident was not permitted to return due to behavioral concerns, despite the facility's awareness of these behaviors at the time of admission. Facility policy states that residents must be permitted to return following hospitalization unless specific criteria are met and that not permitting a resident to return constitutes a discharge. The lack of documentation and failure to follow the required discharge process could result in residents not having the opportunity to appeal the discharge, as noted in the findings.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred from the facility. Resident R47, who had diagnoses of intellectual disabilities, dementia, and major depressive disorder, was transferred to the hospital after exhibiting symptoms such as elevated blood pressure, right-sided facial droop, and left arm weakness. Despite the transfer, there was no documented evidence that the facility communicated the resident's care plan goals, advanced directive information, or specific instructions for ongoing care to the hospital. Similarly, Resident R76, who had diagnoses of high blood pressure, depression, and dementia, was transferred to the hospital due to elevated blood pressure and a headache. The facility also failed to document the communication of necessary information to the receiving health care provider, including the resident's care plan goals, advanced directive information, and resident representative information. During an interview, the Nursing Home Administrator confirmed the lack of evidence that the necessary information was communicated to the receiving health care institution for these two residents. This deficiency was identified based on a review of facility policies, resident records, and staff interviews.
Plan Of Correction
1. The facility is unable to go back and make certain that specific information was communicated to the receiving health care provider during resident transfers. 2. DON/designee to educate licensed staff on comprehensive transfer protocol regarding providing specific information to receiving health care provider and appropriate documentation on the event. 3. DON/designee to audit hospital transfers to ensure proper documentation is sent 5x/week for 2 weeks, then 3x/week for 2 weeks, and 1x/week for 2 weeks. 4. Results to be submitted to QAPI for review and approval.
Failure to Provide Proper Discharge Documentation and Planning
Penalty
Summary
The facility failed to properly discharge a resident by not providing all necessary information and documentation required for a safe and effective transition of care. The resident, who had significant medical and cognitive impairments including vascular dementia, major depressive disorder, type 2 diabetes with neuropathy, and bilateral below-knee amputations, was not his own responsible party. The facility issued a discharge notice for non-payment but did not document a discharge summary, discharge plan, or provide adequate notification to the resident, responsible party, or ombudsman. The discharge notice also lacked a specific address for the resident's discharge destination. Record review showed no evidence of discharge planning discussions or documentation in the nursing progress notes. Interviews with facility staff revealed that the discharge process was still ongoing, with no finalized plan or summary in place. The ombudsman and responsible party were not properly informed, and there was confusion among staff regarding the resident's discharge status and destination. The resident expressed concerns about not receiving sufficient help with his Medicaid application and uncertainty about his ability to return home, while the responsible party indicated the resident's previous home was uninhabitable and that family support was unavailable. Facility policy requires documentation of the basis for discharge and a plan to ensure a safe transition, but these steps were not followed. The lack of a documented discharge summary, plan, and proper notification could compromise the resident's continuity of care and transition to an appropriate setting, as the facility had not determined a safe discharge location or communicated effectively with all involved parties.
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