Beacon Rehabilitation and Nursing Center
February 21, 2017 Complaint Survey

Standard Health Citations

FF10 483.15(c)(2)(ii):DOCUMENTATION FOR TRANSFER/DISCHARGE OF RES

REGULATION: (c)(2) Documentation. (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- [483.15(c)(2)(i) will be implemented beginning November 28, 2017 (Phase 2 )] (A) The resident?s physician when transfer or discharge is necessary under paragraph 483.15(c)(1)(A) or (B) of this and (B) A physician when transfer or discharge is necessary under paragraph 483.15(c)(1)(i)(C) or (D).

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey, the facility did not ensure that residents' physicians documented the specific needs of each resident that could not be met at the facility and/or the reason for transfer to another nursing home for 3 of 3 residents reviewed for admission, transfer and discharge rights (Residents #1, #2 and #3). The findings are: Complaint Number: NY 502 1. Resident #1 is a [AGE] year old admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. According to the 11/16/16 Minimum Data Set (MDS, an assessment tool), the resident had a BIMS (Brief Interview for Mental Status) score of 6 out of a possible score of 15, suggesting that the resident is severely cognitively impaired. The MDS also identified that the resident had clear speech with the ability to understand others and make herself understood, demonstrated no physical, verbal or other behavioral symptoms, required the extensive assistance of one person for transferring, dressing, toilet use and hygiene and received no special treatments or programs. The Resident Face Sheet in the clinical record identified that the resident has a guardian. The resident's Comprehensive Care Plan (CCP) for Discharge included the following entries: 5/23/16 Resident is a LTP (Long Term Placement) secondary to care needs. Team is aware. 8/15/16 Resident is a LTP secondary to care. Team is aware. 11/13/16 Quarterly Note: LTP Is appropriate secondary to care/DX (diagnosis) Team is aware. 12/27/16 Re: Transfer: Resident denied (transfer and admission to another) Nursing Home (NH #1). Team is aware NOK (Next of Kin). 12/29/16 SW (Social Worker) faxed PRI/Screen for long term care to (another) Nursing Home (NH #2) and (another nursing home admitting department) (NH #3). Team and Guardian are aware. (A PRI/Screen is an assessment tool that identifies a resident's diagnoses, conditions and needs required to be completed by a nursing home where a resident resides and used by a nursing home where the resident wishes to transfer to evaluate whether the resident can be accommodated at the potential receiver nursing home). 12/29/16 Resident accepted for (transfer and admission to NH #2), team and Guardian are aware. The resident was transferred to NH #2 on 12/29/16. The resident's CCP for Discharge did not specify a reason for transfer to another nursing home. The resident transfer form dated 12/29/16 did not document a reason for transfer. All progress notes, including physician and SW notes, were reviewed from 2/26/16 - 11/29/16. There was no documented evidence that a physician identified and documented a reason for transfer of the resident to another nursing home. Specifically, the physician did not document that transfer to another nursing home was necessary for the welfare of the resident as the resident's needs could not be met at the facility or that the resident's condition improved to the extent that the resident no longer needed the services of the facility. The facility Transfer and Discharge Policy, with effective date of 11/2008 and revision date of 11/2016, stated that the facility permits each resident to remain in the facility and not transfer or discharge the resident from the facility unless it is necessary for the resident's welfare and the resident's needs cannot be met after reasonable attempts at accommodation in the facility or the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. Documentation in the clinical record is completed by the interdisciplinary team and the physician when transfer or discharge is necessary and includes assessment and attempts to address the resident's needs and behavior. Attempts to contact the resident's physician by phone to determine the reason for transfer of the resident to another nursing home after residing in the facility for more than nine years were unsuccessful on 2/14/17 and 2/21/17. The Physician's Assistant (PA) representing the resident's physician was interviewed on 2/21/17 at 11:00 AM. The PA stated that he could not clearly recall Resident #1 but did remember her situation was similar to that of Resident #2 in that she had psychiatric and behavioral issues that were better suited for treatment at (NH #2). The PA stated that the facility is better suited to address short term needs but not as equipped to address long term psychiatric needs as (NH #2). The PA, when asked about knowledge of regulatory requirements for documenting reason for transfer, stated that he was not able to address the question. 2. Resident #2 is a [AGE] year old admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had current physician's orders [REDACTED]. The Brief Interview for Mental Status (BIMS) score identified on the 10/14/16 MDS was documented as 5 out of a possible score of 15 suggesting that the resident was severely cognitively impaired. The MDS also identified that the resident had clear speech, was usually able to understand others and make himself understood, demonstrated no physical, verbal or other behaviors, required varying levels of assistance from one person to perform ADLs (activities of daily living) and received no special treatments or programs. A SW documented in SWP notes that the resident was readmitted to the facility on [DATE] from the hospital secondary to aggressiveness with an uncertain discharge plan. The SW documented that the resident was again noted as agitated on 6/20/16, transferred and admitted to the hospital, and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The plan was to send the resident to (an adult home) after treatment and therapy. The SW documented on 7/5/16 that there was an inability to reach numbers provided by the resident's former adult home residence. The SW further documented that discharge was uncertain secondary to care needed. The SW documented in a 9/20/16 note that a return to the resident's prior adult home was questionable secondary to diagnosis, care and confusion. Additional SWP notes entries included: 10/26/16 SWP note documented that the resident is LTP secondary to care. 11/15/16 SWP note documented transfer plans for SNF (skilled nursing facility) placement. PRI/Screen and medication sheets were faxed to NH #3. 11/16/16 SWP note documented that the resident was accepted to NH #3 and that the team and resident were aware. 11/17/16 SWP note documented that the resident was transferred. All progress notes during this same period of time were reviewed with no documentation by the physician identifying a reason for transfer to another nursing home. An entry in the Comprehensive Care Plan (CCP) for discharge date d 11/16/16 documented that the Resident and team are aware resident to transfer to (NH #3) on Thursday, 11/17 at 10 am via ambulette as resident requires a long term more skilled facility. Transfer form to accompany resident. The resident's needs that the facility could not meet and the reason(s) why meeting the resident's needs required a more skilled facility were not specified in the CCP. The Notice of Discharge and Transfer Document dated 11/17/16 was reviewed. Inconsistent with the CCP statement that the needs of the resident required a more skilled facility, the Notice of Discharge and Transfer Document identified that transfer was necessary because the resident's health has improved sufficiently to allow a more immediate transfer in that the services of the facility were no longer needed; needs could be better met at NH #3 based on the resident's diagnosis. No physician's signature or physician's identification of what needs would be better met by the receiving facility were documented on this form. Nor did the physician document how the resident's health had improved or why transfer to another nursing home was then appropriate. Attempts to contact the resident's physician by phone to determine the reason for transfer of the resident to another nursing home after residing in the facility for more than four years were unsuccessful on 2/14/17 and 2/21/17. The Physician's Assistant (PA) representing the resident's physician was interviewed on 2/21/17 at 11:00 AM. The PA stated that he was familiar with Resident #2 and recalled him admitted following a subdural hematoma for a short term rehab stay. The PA recalled that the resident had psychiatric changes that may have been associated with his hematoma leading to behavioral problems that could be better addressed at (NH #3). The PA stated that he felt that (NH #3) was better suited for long term treatment for [REDACTED]. 3. Resident #3 is an [AGE] year old admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Currently ordered medications included [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) dated 12/11/16 identified that the resident had short term and long term memory loss with moderately impaired decision making ability. The MDS also identified that the resident had clear speech with the ability to sometimes understand others and make himself understood, demonstrated no physical, verbal or other behavioral symptoms, primarily required the extensive assistance of one person to perform ADLs and received no special treatments or programs. The Comprehensive Care Plan (CCP) for Discharge included the following entries: 12/30/15 LTC (Long Term Care) placement is appropriate. Continue with CCP. 3/31/16 LTP is appropriate. Plan of care continues. Team is aware. 6/28/16 LTP is appropriate secondary to care. Team is aware P(NAME) (Plan of Care) continues. 9/25/16 LTP is appropriate secondary to care/DX. Team is aware. 12/27/16 LTP is appropriate secondary to care/team is aware. 12/27/16 RE: Transfer Plans: Resident denied (transfer and admission to another nursing home). Team is aware. Next of kin does not wish to be called. Social Work Progress notes revealed that no evidence of resident behaviors or mood indicators were documented in the period from 3/14/16 to the time of discharge. SWP note entries included: 10/26/16 SWP documented that the resident was seen by psychiatry and [MEDICATION NAME] was decreased. 11/14/16 SWP documented that SW had contact with a family member to clarify contact going forward to include emergency or expiration of the resident. 12/6/16 SWP documented possible discharge plans and a referral to (a named) Adult Home. 12/12/16 SWP documented that a PRI and Screen and medication list was sent to (another nursing home) 12/27/16 transfer and admission to the other nursing home above was denied. 12/30/16 SWP note documented that the resident was transferred to (NH #4) and the family member was notified of the transfer. All progress notes during this period of time, including physician and SW notes, were reviewed. There was no documented evidence that a physician identified and documented a reason for transfer of the resident to another nursing home. Specifically, the physician did not document that transfer to another nursing home was necessary for the welfare of the resident as the resident's needs could not be met at the facility or that the resident's condition improved to the extent that the resident no longer needed the services of the facility. The Notice of Discharge and Transfer Document dated 12/27/16 identified that the transfer was necessary because the resident's health has improved sufficiently to allow a more immediate transfer as the services of the facility were no longer needed and needs could be better met at another nursing home. No physician's signature or identification by the resident's physician of how the resident's health had improved sufficiently, why transfer to another nursing home would then be appropriate or what needs would be better met by the receiving facility were documented on this form. The resident's physician was interviewed by phone on 2/21/17 at 11:10 AM to determine the reason for transfer of the resident to another nursing home after residing in the facility for more than one and a half years. The physician stated that the resident previously resided in (NH #4), was discharged to an Adult Home, hospitalized and ultimately transferred to the facility for short term rehab. The physician stated that the resident was supposed to go to (NH #4) following hospitalization but a bed was not available at that time, therefore he was transferred to the facility. The physician stated that the resident is better suited for long term treatment at (NH #4) because she felt that (NH #4) is better equipped to manage Dementia than the facility is. Upon inquiry, the physician stated that she was not familiar with the discharge documentation requirements and has always documented only an order for [REDACTED]. 415.3(h)(1)(ii)(a)(b)

Plan of Correction: ApprovedMarch 10, 2017

Plan of Correction: F202
I. Immediate Corrective Action
The Director of Nursing reviewed all residents who were identified for potential transfer, to an alternate facility, to ensure that the physician identified, in the physician discharge summary, the specific need of the resident that could not be met at the facility.
II. Identification of other Residents
The facility respectfully states that all Residents where potentially affected by this deficient practice.
III. Systemic Changes
Physician discharge summary was revised to specify the reason for transfer to another nursing facility.
All Physicians were in-serviced regarding documenting the specific need of the resident that the facility could not meet and the specific reason for transfer. The Director of Nursing in-serviced the physicians regarding the revision to the physician discharge summary by 3/10/17.
IV. Quality Assurance
The Director of Nursing /designee will perform an audit, on all residents who are transferred to alternate skilled nursing facility, to ensure that the physician documented the specific reason for the transfer and the need of the resident that could not be met at the facility. This audit will be done monthly x 3 and quarterly thereafter. The results of this will be presented to the administrator and to the QAPI committee, quarterly, for review.
V. The Person Responsible for this FTag
The Director of Nursing is responsible for correcting this FTag deficiency

FF10 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: (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 (b)(5) of this section. (c) (4) Timing of the notice. (i) Except as specified in paragraphs (b)(4)(ii) and (b)(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 (b)(1)(ii)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (b)(1)(ii)(D) of this section; (C) The resident?s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (b)(1)(ii)(B) of this section; (D) An immediate transfer or discharge is required by the resident?s urgent medical needs, under paragraph (b)(1)(ii)(A) of this section; or (E) A resident has not resided in the facility for 30 days. (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. (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. (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).

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey, the facility did not ensure that the legal representatives for 3 of 3 residents reviewed for transfer and discharge rights (Residents #1, #2 and #3) were provided with written notification of transfer that included reasons for transfer, date, transfer location, appeal rights and ombudsman contact information, at least 30 days prior to transfer of the residents from the facility. Additionally, specific reasons for transfer were not documented in the residents' clinical records. The findings are: Complaint Number: NY 502 1. Resident #1 is a [AGE] year old admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. According to the 11/16/16 Minimum Data Set (MDS, an assessment tool), the resident had a BIMS (Brief Interview for Mental Status) score of 6 out of a possible score of 15, suggesting that the resident is severely cognitively impaired. The MDS also identified that the resident had clear speech with the ability to understand others and make herself understood, demonstrated no physical, verbal or other behavioral symptoms, required the extensive assist of one person for transferring, dressing, toilet use and hygiene and received no special treatments or programs. The Resident Face Sheet in the clinical record identified that the resident has a guardian. Social Work Progress notes (SWP notes) revealed that the Social Worker (SW) was aware of and able to contact the resident's guardian to communicate verbally and in writing as follows: 4/18/16 SWP note documented that a medical report was completed and faxed to the guardian. 6/27/16 SWP note documented that requested information was sent to the guardian. 8/23/16 SWP note documented contact with the guardian. SW was informed that a new guardian was assigned. The resident's Comprehensive Care Plan (CCP) for Discharge included the following entries: 5/23/16 Resident is a LTP (Long Term Placement) secondary to care needs. Team is aware. 8/15/16 Resident is a LTP secondary to care. Team is aware. 11/13/16 Quarterly Note: LTP is appropriate secondary to care /DX (diagnosis) Team is aware. Subsequent CCP entries revealed a change in plan for LTP for the resident, active attempts by the facility to transfer the resident to another nursing home and documentation that the resident's guardian was notified, as follows: 12/27/16 Re: Transfer: Resident denied (transfer and admission to another) Nursing Home (NH #1). Team is aware NOK (Next of Kin). 12/29/16 SW (Social Worker) faxed PRI/Screen for long term care to (another) Nursing Home (NH #2) and (another nursing home admitting department) (NH #3). Team and Guardian are aware. (A PRI/Screen is an assessment tool that identifies a resident's diagnoses, conditions and needs required to be completed by a nursing home where a resident resides and used by a nursing home where the resident wishes to transfer to evaluate whether the resident can be accommodated at the potential receiver nursing home). 12/29/16 Resident accepted for (NH #2), team and Guardian are aware. There was no documented evidence of attempts to involve the legal representative guardian in transfer/discharge planning in the care planning notes or progress notes for this period. There was no documented evidence that the resident or guardian received written notification prior to, or at the time of, the transfer or that the resident or guardian consented to the transfer. SWP notes included the following entries that also revealed a change in plan for the resident from LTP to transfer to another nursing home: 12/12/16 SWP note documented that a PRI/Screen was faxed to NH #1. The SW documented that a message was left for the guardian. 12/27/16 SWP note documented that the resident was denied admission to NH #1. 12/29/16 SWP note documented that PRI/Screen was faxed to NH #3 and NH #2. The SW documented that she notified the guardian. Another SWP note written by the SW on 12/29/16 documented that the resident was accepted to NH #2 and that the resident was transferred to this nursing home. The note documented that two messages were left with the guardian. According to the SWP notes above, the SW left messages for the guardian on 12/12/16 and 12/29/16, the day the resident was transferred to NH #2. There was no documented evidence that the guardian was verbally notified of transfer 30 days prior to the transfer or that the guardian received these messages from the SW on 12/12/16 or 12/29/16. There was no documented evidence that the guardian was provided with written notification of transfer that included the reason(s) for transfer, date, transfer location, the right to appeal the action to the State, and contact information for the State long term care ombudsman, at least 30 days prior to transfer of the resident from the facility. There was no documented evidence that a Discharge Notice upon transfer of the resident from the facility was received by the guardian. The Director of Social Work (DSW) was interviewed on 1/25/17 at 2:00 PM. The DSW stated that multiple attempts were made to reach the guardian by telephone about the transfer without success. The DSW further stated that a notification of pending discharge 30 days prior to discharge was not mailed to or signed by the guardian, nor was a written discharge notice mailed to the guardian, and that the resident does not have the capacity to understand the process or notifications. The DSW also stated during the interview above that the resident was transferred to the other facility because the other facility is better equipped to handle behavioral patients. The DSW stated that she did not recall documenting a reason for transfer or discharge planning anywhere in the medical records. The Director of Nursing (DON) was interviewed at 9:35 AM and at 12:05 PM on 1/25/17. The DON denied any knowledge of any behavioral problems with the resident or any knowledge of the rationale for the resident's discharge planning. The DON stated that she believed the resident to be a behavioral patient but provided no verbal examples or documented evidence of any recent behavioral issues. Social Work Progress notes were reviewed for the period of 2/22/16 to the time of discharge. No indication of any behavioral issues were documented during the period reviewed. Psychiatric consultations dated 6/16/16, 9/7/16 and 12/6/16 were reviewed with no documentation of any behavioral disturbances. No reasons for transfer to another nursing home were documented in the SWP notes, reviewed from 2/22/16 to the time of discharge on 12/29/16, the resident transfer form, the physician's progress notes or elsewhere in the clinical record. The facility Transfer and Discharge Policy, with effective date of 11/2008 and revision date of 11/2016, includes statements that the facility permits each resident to remain in the facility and not transfer or discharge the resident from the facility unless it is necessary for the resident's welfare and the resident's needs cannot be met after reasonable attempts at accommodation in the facility or the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. Documentation in the clinical record is completed by the interdisciplinary team and the physician when transfer or discharge is necessary and includes assessment and attempts to address the resident's needs and behavior. The Policy also included Procedures that stated to notify the resident and designated representative of the transfer or discharge and reasons in writing or phone call. Record in the resident's clinical records; and/or provide the notice of transfer or discharge required at least 30 days before the resident is transferred or discharged . According to the Procedures, contents of the written notice include reason for the transfer or discharge, effective date, location, statement that the resident has the right to appeal to the State, the Long Term Care Ombudsman. According to the facility Admission Agreement Section VII (b), The Facility may transfer or discharge the Resident if the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met after reasonable attempts at accommodation in the facility; the resident's health has improved sufficiently so the resident no longer needs the services provided by the Facility; the health or safety of individuals in the Facility would otherwise be endangered and all reasonable alternatives to transfer or discharge have been explored and have failed to safely address the problem; and for any other reason permitted by applicable law. 2. Resident #2 is a [AGE] year old admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had current physician's orders [REDACTED]. The Brief Interview for Mental Status (BIMS) score identified in the 10/14/16 MDS was documented as 5 out of a possible score of 15 suggesting that the resident was severely cognitively impaired. The MDS also identified that the resident had clear speech, was usually able to understand others and make himself understood, demonstrated no physical, verbal or other behaviors, required varying levels of assistance from one person to perform ADLs (activities of daily living) and received no special treatments or programs. A SW documented in SWP notes that the resident was readmitted to the facility on [DATE] from the hospital secondary to aggressiveness with an uncertain discharge plan. The SW documented that a family member of the resident was involved. The SW documented that the resident was again noted as agitated on 6/20/16, transferred and admitted to the hospital, and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The plan was to send the resident to (an adult home) after treatment and therapy. The SW documented on 7/5/16 that there was no involved family and an inability to reach numbers provided by the resident's former adult home residence. The SW further documented that discharge was uncertain secondary to care needed. The SW documented in a 9/20/16 note that a return to the resident's prior adult home was questionable secondary to diagnosis, care and confusion and that the resident was unable to understand a comprehensive care plan meeting invitation or resident's rights. Additional SWP notes entries included: 10/26/16 SWP note documented that the resident is LTP secondary to care. 11/15/16 SWP note documented transfer plans for SNF (skilled nursing facility) placement. PRI/Screen and medication sheets were faxed to NH #3. 11/16/16 SWP note documented that the resident was accepted to NH #3 and that the team and resident were aware with no involved next of kin. 11/17/16 SWP note documented that the resident was transferred with no next of kin to contact. The Comprehensive Care Plan (CCP) for Discharge included the following entry: 11/16/16 Resident and team are aware resident to transfer to NH #3 on Thursday, 11/17 at 10 am via ambulette as resident requires a long term more skilled facility. Transfer form to accompany resident. No next of kin to contact. All progress notes were reviewed during this same review period with no documentation by the physician identifying a reason for transfer to another nursing home. The resident's needs that the facility could not meet and the reason(s) why meeting the resident's needs required a more skilled facility were not specified in the CCP. The Notice of Discharge and Transfer Document dated 11/17/16 was reviewed. Inconsistent with the CCP statement that the needs of the resident required a more skilled facility, the Notice of Discharge and Transfer Document identified that transfer was necessary because the resident's health has improved sufficiently to allow a more immediate transfer in that the services of the facility were no longer needed; needs could be better met at NH #3 based on the resident's diagnosis. No physician's signature or physician's identification of what needs would be better met by the receiving facility were documented on this form or how the resident's health had improved or why transfer to another nursing home was then appropriate. No resident or family signatures were found on the document other than a note stating that the resident is confused and there was no next of kin to notify. There was no documented evidence of attempts to provide written notice of transfer to the resident's family member, identified by the SW in the 6/2/16 SWP note as being involved, including the reason(s) for transfer, date, transfer location, the right to appeal the action to the State, and contact information for the State long term care ombudsman, at least 30 days prior to transfer of the resident from the facility. The DSW was interviewed on 1/25/17 at 2:00 PM and stated that the resident was transferred to the other facility because the other facility is better equipped to handle behavioral patients. The DSW stated that she did not recall documenting a reason for transfer or discharge planning anywhere in the medical records and did not recall any immediate behavioral problems that the resident had, other than an incident in (MONTH) when the resident was grabbing staff and was hospitalized . The DSW stated that a discharge notice was not signed by or mailed to the family, nor was a notification of pending discharge 30 days prior to discharge mailed. The DON was interviewed at 9:35 AM and at 12:05 PM on 1/25/17 and stated that she had no knowledge of any behavioral problems with the resident or any knowledge of the rationale for the resident's discharge planning. The DON stated that she believed the resident to be a behavioral patient but provided no verbal examples or documented evidence of any recent behavioral issues, other than an incident in (MONTH) when the resident was grabbing staff and was hospitalized . 3. Resident #3 is an [AGE] year old admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Currently ordered medications included [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) documented in the MDS dated [DATE] identified that the resident had short term and long term memory loss with moderately impaired decision making ability. The MDS also identified that the resident had clear speech with the ability to sometimes understand others and make himself understood, demonstrated no physical, verbal or other behavioral symptoms, primarily required the extensive assistance of one person to perform ADLs and received no special treatments or programs. The Comprehensive Care Plan (CCP) for Discharge included the following entries: 12/30/15 LTC (Long Term Care) placement is appropriate. Continue with CCP. 3/31/16 LTP is appropriate. Plan of care continues. Team is aware. 6/28/16 LTP is appropriate secondary to care. Team is aware P(NAME) (Plan of Care) continues. 9/25/16 LTP is appropriate secondary to care/DX. Team is aware. 12/27/16 LTP is appropriate secondary to care/team is aware. 12/27/16 RE: Transfer Plans: Resident denied (transfer and admission to another nursing home). Team is aware. Next of kin does not wish to be called. Social Work Progress notes revealed that no evidence of resident behaviors or mood indicators were documented in the period from 3/14/16 to the time of discharge. SWP note entries included: 10/26/16 SWP documented that the resident was seen by psychiatry and [MEDICATION NAME] was decreased. 11/14/16 SWP documented that SW had contact with a family member to clarify contact going forward to include emergency or expiration of the resident. There was no documented evidence that the possibility of the resident being transferred to another nursing home was discussed with the family member in order to determine if the family member would want to be notified of such an occurrence. 12/6/16 SWP documented possible discharge plans and a referral to (a named) Adult Home. 12/12/16 SWP documented that a PRI and Screen and medication list was sent to (another nursing home) 12/27/16 transfer and admission to the other nursing home above was denied. 12/30/16 SWP note documented that the resident was transferred to (NH #4) and the family member was notified of the transfer. All progress notes during this period of time, including physician and SW notes, were reviewed. There was no documented evidence of attempts to provide written notice of transfer to the resident's family member including the reason(s) for transfer, date, transfer location, the right to appeal the action to the State, and contact information for the State long term care ombudsman, at least 30 days prior to transfer of the resident from the facility. There was no documented evidence that a physician identified and documented a reason for transfer of the resident to another nursing home. Specifically, the physician did not document that transfer to another nursing home was necessary for the welfare of the resident as the resident's needs could not be met at the facility or that the resident's condition improved to the extent that the resident no longer needed the services of the facility. The Notice of Discharge and Transfer Document, dated 12/27/16 was reviewed. The document identified that the transfer and discharge was necessary because the resident's health has improved sufficiently to allow a more immediate transfer of discharge being that the services of the facility were no longer needed as needs could be better met at another nursing home. No resident or family signatures were found on the document other than a note stating that the family member was notified and only involved in d/c (discharge) and emergency. The DSW was interviewed on 1/25/17 at 2:00 PM and stated that multiple attempts were made to reach the family member by telephone without success. The DSW stated that notifications were not mailed to the family member and that the resident does not have the capacity to understand the process or notifications. The DSW stated that the resident's family member indicated that she did not want to be contacted for any reason other than emergency or expiration. She stated that a discharge notice was not signed by or mailed to the family, nor was a notification of pending discharge 30 days prior to discharge mailed. The DSW stated that she did not recall documenting a reason for transfer or discharge planning anywhere in the medical records. The DSW stated that the resident was transferred to the other facility because the other facility is better equipped to handle behavioral patients. The DON was interviewed at 9:35 AM and at 12:05 PM on 1/25/17 and stated that she had no knowledge of any behavioral problems with the resident or any knowledge of the rationale for the resident's discharge planning. The DON stated that she believed the resident to be a behavioral patient but did not provide verbal examples or documented evidence of any recent behavioral issues. 415.3(h)(1)(iii)(a-c)

Plan of Correction: ApprovedMarch 10, 2017

Plan of Correction: F203
I. Immediate Corrective Action
The Director of Social Services audited all residents, who were identified for potential transfer/ discharge from the facility, to another nursing home, to ensure that the resident and/or legal representative/family member were provided with written notification of the transfer which includes the specific reason for the transfer, date of transfer, transfer location, appeal rights and Ombudsman contact information.
II. Identification of other Residents
The facility respectfully states that all Residents where potentially affected by this deficient practice.
III. Systemic Changes
The policy for resident transfer/discharge was reviewed and revised. The Director of Social Services formulated a discharge/transfer checklist to ensure that the all residents identified, for transfer, are provided with a written notification of transfer which includes the specific reason for the resident?s transfer, date of transfer, transfer location, appeals right with contact information to the Ombudsman.
Director of Social Services in-serviced the social service department regarding the discharge/transfer checklist by 3/8/17.
IV. Quality Assurance
The Director of Social Services /designee will perform an audit to ensure compliance. Auditing will be conducted monthly for 3 months and quarterly, thereafter, for compliance with the policy and procedure. The results of this, will be presented to the administrator and to the QAPI committee, quarterly, for review.

V. The Person Responsible for this FTag
The Director of Social Services is responsible for correcting this FTag deficiency.

FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during an abbreviated survey, the facility did not provide immediate notification of the facility decision to transfer residents to other nursing homes to the residents' legal representatives and/or interested family members for 3 of 3 residents reviewed for transfer and discharge (Residents #1, #2 and #3). The findings are: Complaint Number: NY 502 1. Resident #1 is a [AGE] year old admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. According to the 11/16/16 Minimum Data Set (MDS, an assessment tool), the resident had a BIMS (Brief Interview for Mental Status) score of 6 out of a possible score of 15, suggesting that the resident is severely cognitively impaired. The Resident Face Sheet in the clinical record identified that the resident has a guardian. According to a 12/29/16 Social Work Progress (SWP) note, the resident was transferred to another nursing home. The note documented that two messages were left with the guardian. There was no documented evidence that the guardian received these messages from the SW or that the guardian was provided with written notification of the transfer. The Director of Social Work (DSW) was interviewed on 1/25/17 at 2:00 PM. The DSW stated that multiple attempts were made to reach the guardian by telephone about the transfer without success. The DSW further stated that a notification of pending discharge 30 days prior to discharge was not mailed to or signed by the guardian, nor was a written discharge notice mailed to the guardian, and that the resident does not have the capacity to understand the process or notifications. The facility Transfer and Discharge Policy, with effective date of 11/2008 and revision date of 11/2016, included Procedures that stated to notify the resident and designated representative of the transfer or discharge and reasons in writing or phone call. Record in the resident's clinical records; and/or provide the notice of transfer or discharge required at least 30 days before the resident is transferred or discharged . 2. Resident #2 is a [AGE] year old admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score identified in the 10/14/16 MDS was documented as 5 out of a possible score of 15 suggesting that the resident was severely cognitively impaired. A SW (Social Worker) documented in a 6/2/16 SWP note that a family member of the resident was involved. The SW documented in a 11/17/16 SWP note that that the resident was transferred to another nursing home with no next of kin to contact. The Notice of Discharge and Transfer Document dated 11/17/16 was reviewed. No resident or family signatures were found on the document other than a note stating that the resident is confused and there was no next of kin to notify. There was also no documented evidence of attempts to provide written notice of transfer to the resident's family member, identified by the SW in the 6/2/16 SWP note as being involved, including the reason(s) for transfer, date, transfer location, the right to appeal the action to the State, and contact information for the State long term care ombudsman, at least 30 days prior to transfer of the resident from the facility. The DSW was interviewed on 1/25/17 at 2:00 PM and stated that a discharge notice was not signed by or mailed to the family, nor was a notification of pending discharge 30 days prior to discharge mailed. 3. Resident #3 is an [AGE] year old admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) documented in the MDS dated [DATE] identified that the resident had short term and long term memory loss with moderately impaired decision making ability. An 11/14/16 SWP note documented that a SW had contact with a family member to clarify contact going forward to include emergency or expiration of the resident. There was no documented evidence that the possibility of the resident being transferred to another nursing home was discussed with the family member in order to determine if the family member would want to be notified of such an occurrence. A 12/30/16 SWP note documented that the resident was transferred to another nursing home and the family member was notified of the transfer. All progress notes during this period of time, including physician and SW notes, were reviewed. There was no documented evidence of attempts to provide written notice of transfer to the resident's family member including the reason(s) for transfer, date, transfer location, the right to appeal the action to the State, and contact information for the State long term care ombudsman, at least 30 days prior to transfer of the resident from the facility. The Notice of Discharge and Transfer Document, dated 12/27/16 was reviewed. No resident or family signatures were found on the document other than a note stating that the family member was notified and only involved in d/c (discharge) and emergency. The DSW was interviewed on 1/25/17 at 2:00 PM and stated that multiple attempts were made to reach the family member by telephone without success. The DSW stated that notifications were not mailed to the family member and that the resident does not have the capacity to understand the process or notifications. The DSW stated that the resident's family member indicated that she did not want to be contacted for any reason other than emergency or expiration. She stated that a discharge notice was not signed by or mailed to the family, nor was a notification of pending discharge 30 days prior to discharge mailed. 415.3(e)(2)(ii)(d)

Plan of Correction: ApprovedMarch 10, 2017

Plan of Correction: F157
I. Immediate Corrective Action
The Director of Social Services audited all residents who were identified for potential transfer/ discharge from the facility, to another nursing home, to ensure that timely notification of the facility?s decision to transfer was provided to the resident and/or resident?s legal representative and/ or interested family member.

II. Identification of other Residents
The facility respectfully states that all Residents where potentially affected by this deficient practice.
III. Systemic Changes
The policy for resident transfer/discharge was reviewed and revised. The Director of Social Services formulated a discharge/transfer checklist to ensure the immediate notification to the resident and/or resident?s legal representative/interested family member of the facility?s decision to transfer to another nursing home.
Director of Social Services in -serviced the social service department regarding the discharge/transfer checklist and revised policy by 3/8/17.
IV. Quality Assurance
The Director of Social Services /designee will perform an audit, to ensure that residents, identified for transfer to another nursing facility, have been notified and/or their legal representative/interested family member. The audit will be done, monthly x 3 and quarterly thereafter. The results of this will be presented to the administrator and to the QAPI committee, quarterly, for review.
V. The Person Responsible for this FTag
The Director of Social Services is responsible for correcting this FTag deficiency.

FF10 483.15(c)(7):PREPARATION FOR SAFE/ORDERLY TRANSFER/DISCHRG

REGULATION: (c)(7) Orientation for Transfer or Discharge A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey, the facility did not ensure that sufficient preparation and orientation for transfer to another nursing home was provided to 3 of 3 residents and/or designated representatives reviewed for admission, transfer and discharge rights (Residents #1, #2 and #3). The findings are: Complaint Number: NY 502 1. Resident #1 is a [AGE] year old admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. According to the 11/16/16 Minimum Data Set (MDS, an assessment tool), the resident had a BIMS (Brief Interview for Mental Status) score of 6 out of a possible score of 15, suggesting that the resident is severely cognitively impaired. The MDS also identified that the resident had clear speech with the ability to understand others and make herself understood, demonstrated no physical, verbal or other behavioral symptoms, required the extensive assist of one person for transferring, dressing, toilet use and hygiene and received no special treatments or programs. The Resident Face Sheet in the clinical record identified that the resident has a guardian. According to a Social Work Progress note, the resident was transferred to another nursing home on 12/29/16. Social Work Progress notes, the Comprehensive Care Plan for Discharge and other progress notes were reviewed for the period of 2/22/16 to the time of discharge. There was no documented evidence of attempts to involve the resident and/or designated representative in discharge planning, selection of a new residence for the resident, visiting the transfer location, allowing the resident to meet other residents and staff at the receiving facility or orienting staff at the receiving facility to the resident's customary routines in order to promote well-being and minimize potential anxiety or depression for the resident related to the transfer after residing in the facility for more than nine years. The Director of Social Work was interviewed on 1/25/17 at 2:00 PM and provided no evidence of attempts to orient or prepare the resident for transfer. The Director of Social Work stated that multiple attempts were made to reach the guardian by telephone without success and that written notice of transfer was not sent. 2. Resident #2 is a [AGE] year old admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had current physician's orders [REDACTED]. The Brief Interview for Mental Status (BIMS) score identified in the 10/14/16 MDS was documented as 5 out of a possible score of 15 suggesting that the resident was severely cognitively impaired. The MDS also identified that the resident had clear speech, was usually able to understand others and make himself understood, demonstrated no physical, verbal or other behaviors, required varying levels of assistance from one person to perform ADLs (activities of daily living) and received no special treatments or programs. According to a 6/2/16 Social Work Progress (SWP) note, the resident had an involved family member. An 11/17/16 SWP note documented that the resident was transferred to another nursing home with no next of kin to contact. Social Work Progress notes, the Comprehensive Care Plan for Discharge and other progress notes were reviewed and revealed no evidence of attempts to involve the resident or the resident's family member in discharge planning or a process for orientation and preparation of the resident for transfer to another nursing home after residing in the facility for more than four years. The Director of Social Work was interviewed on 1/25/17 at 2:00 PM and provided no evidence of interventions to prepare the resident and/or designated representative for transfer. 3. Resident #3 is an [AGE] year old admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Currently ordered medications included [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) documented in the MDS dated [DATE] identified that the resident had short term and long term memory loss with moderately impaired decision making ability. The MDS also identified that the resident had clear speech with the ability to sometimes understand others and make himself understood, demonstrated no physical, verbal or other behavioral symptoms, primarily required the extensive assistance of one person to perform ADLs and received no special treatments or programs. According to a 12/30/16 SWP note, the resident was transferred to another nursing home. Social Work Progress notes, the Comprehensive Care Plan for Discharge and other progress notes were reviewed and revealed no evidence of attempts to involve the resident or the resident's family member in discharge planning or a process for orientation and preparation of the resident for transfer to another nursing home after residing in the facility for more than one and one half years. The Director of Social Work was interviewed on 1/25/17 at 2:00 PM and provided no evidence of interventions to prepare the resident and/or designated representative for transfer. The Director of Social Work stated that the resident's family member only wanted to be contacted in the event of emergency or expiration of the resident. 415.3(h)(1)(v)

Plan of Correction: ApprovedMarch 10, 2017

Plan of Correction: F204
I. Immediate Corrective Action
The Director of Social Services audited all residents, which were identified for potential transfer from the facility to another nursing home, that sufficient preparation and orientation was provided to ensure a safe and orderly transfer from the facility.
II. Identification of other Residents
The facility respectfully states that all Residents where potentially affected by this deficient practice.
III. Systemic Changes
The policy for resident transfer/discharge was reviewed and revised. The Social Services Department was in-serviced to educate identified residents and/or legal representative/family member prior to transfer/discharge. The Social Service department was in-serviced to update all identified resident?s progress notes and the care plan to ensure that sufficient orientation and preparations are made and in place prior to transfer to another facility.
The Social Service department was in-serviced by 3/8/17.
IV. Quality Assurance
The Director of Social Services /designee will perform an audit to ensure compliance that all residents, who are identified for transfer, will be provided with sufficient preparation and orientation to ensure a safe and orderly transfer to an alternate skilled nursing facility. Auditing will be conducted monthly for 3 months and quarterly thereafter, to ensure compliance with the policy and procedure. The results of this will be presented to the administrator and to the QAPI committee, quarterly, for review.

V. The Person Responsible for this FTag
The Director of Social Services is responsible for correcting this FTag deficiency.