|The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;|
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;
The safety of individuals in the facility is endangered;
The health of individuals in the facility would otherwise be endangered;
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. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or
The facility ceases to operate.
Based on clinical record review and staff interview, it was determined that the facility failed to establish a need for transfer or discharge from the facility for one of three sampled residents. (Resident CR1)
The facility has 120 beds certified in the Medicare/Medicaid programs licensed by the Commonwealth of Pennsylvania to provide long term care to all residents.
Clinical record review revealed that Resident CR1 was admitted to the facility on October 3, 2013, with diagnoses that included hip fracture and dementia. On October 4, 2013, the responsible party signed the admission agreement that indicated the resident had been admitted to the facility for "Short Term Rehab." During a meeting with the family on October 9, 2013, the family informed the facility that they wished to pursue long term care for the resident. The social worker documented "they were given a list of long term care facilities in the area so that they could call and tour and interview." There was no evidence that they informed the family that the resident could stay there, as she was currently in a long term care facility bed. On October 16, 2013, the resident was transferred to another long term care facility for continued skilled services. There was no documentation that this transfer was warranted or that the facility notified the family at the time of the transfer. In a telephone interview on October 18, 2013, the Administrator stated that the resident was transferred to another nursing home because they did not have a "long term care bed available for the resident." This statement was incorrect as the resident was in a long term care bed.
In an interview on October 21, 2013, at 12:40 p.m., the Administator confirmed that all beds in the facility are certified under the Medicareprograms.
28 Pa. Code 201.29(f) Resident rights.
| ||Plan of Correction - To be completed: 11/15/2013|
(1) In accordance with F 201, 483.12(a)(2), resident CR!1 was discharged/transferred to another facility without acknowledgement or permission from the family. The facility failed to establish a need for transfer or discharge from the facility. Staff should have continued to attempt to communicate with family members regarding their definitive future plans for transfer of the resident. The communication between the discharge planning staff members and the patient and family acknowledges the request of the patient and all concur with the discharge plan. This communication and concurrence with the discharge plan will be clearly documented.
(1) For future questionable or undetermined discharges/transfers, the staff will meet with the family members and resident to clearly outline the timeline and future plans for discharge/transfer. The communication for discharge/transfer will be documented and agreed upon by all parties prior to instituting any discharge/transfer plan. The Policy and Procedure for Discharge/Transfer Planning will be revised to include the requirement for discharge/transfer process according to the requirements of F 201.
(2) Education for all members of the Interdisciplinary Team, including attending MD’s will occur to prevent future occurrences and in compliance with CMS F-TAG 201 (483.12(a)(2)). All residents with unplanned transfers/discharges will require authorization of Administrator and Medical Director.
(3) All “Short Term Post- Acute” resident discharge plans will be monitored via reviewing logs, plans for discharge, family and/or patient notification and concurrence with plans. Analysis of log will be completed and reviewed at monthly QAPI meeting.
Responsibility: Social Service Director, Social Worker, NHA
Completion Date: 11/15/13