Fordham Nursing and Rehabilitation Center
May 8, 2018 Complaint Survey

Standard Health Citations

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §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).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 8, 2018
Corrected date: May 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during an abbreviated survey (NY 727), the facility did not ensure that Office of the State Long Term Care Ombudsman was notified of the transfer/discharge of each discharged resident. This was evident in 6 out of 6 sampled residents, (Resident #1, #2, #3, #4, #5 & #6). Specifically, the facility initiated transfer/discharges for Resident #1, #2, #3, #4, #5  but did not send a copy of the transfer/discharge notice to the Office of the State Long Term Care (LTC) Ombudsman. A Facility Policy and Procedure titled, Discharge/Transfers Rights and Regulations, dated 03/2017 states, it is the responsibility of the Social Worker (SW) to complete the Discharge/Transfer Notice and provide a copy to the resident and representative. Documentation in the medical record, by the Social Worker, should indicate the date the Notice was given and to whom the notice was given, as well as the date and Notice was mailed to the designated representative and the Ombudsman and appropriate information is communicated to the receiving health care institution. The Social Worker will send a copy of the Notice to the Representative/Guardian and the Office of the State Long Term Care Ombudsman via First Class Mail or another communication method as requested. A copy of the notice will be maintained in the medical record. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool)) on 01/23/2018, indicated a BIMS (Brief Interview for Mental Status) cognitively intact. A Transfer /Discharge Notice dated 02/01/2018 documented Resident #1 was given a notice that the facility will discharge him on 02/01/2018 to the hospital with the following reason: This transfer/discharge notice is being issued for your welfare as your needs cannot currently be met by the services available at hospital. The notice documented left hip surgical site possible infection, as a statement of fact that supports the determination to discharge or transfer the resident. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 01/19/2018, indicated a BIMS (Brief Interview for Mental Status) score of 15/15, cognitively intact. A Transfer /Discharge Notice dated 01/16/2018 documented Resident #2 was given a notice that the facility will discharge him on 01/18/2018 to a shelter. The notice did not indicate the reason of why the transfer/discharge notice is being issued. A MD Discharge Summary with an effective date of 01/17/2018, documented the resident was discharged to the community on 01/18/2018. The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 12/12/2017, indicated a BIMS (Brief Interview for Mental Status) score of 15/15, cognitively intact. A Transfer /Discharge Notice dated 12/05/2017 documented Resident #3 was given a notice that the facility will discharge the him on 12/11/2017 to a shelter. The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. A review of the MD Discharge Summary with an effective date of 12/11/2017, documented the resident was discharged to the community on 12/11/2017. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 03/20/2018, indicated a BIMS (Brief Interview for Mental Status) score 15/15, cognitively intact. A review of the Transfer /Discharge Notice dated 03/16/2018 documented Resident #4 was given a notice that the facility will discharge her on 03/20/2018 to a shelter. The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. A review of the MD Discharge Summary with an effective date of 03/19/2018, documented the resident was discharged to the community on 03/20/2018. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS resident assessment tool) on 01/26/2018, indicated a BIMS (Brief Interview for Mental Status) score of 13/15, cognitively intact. A review of the Transfer /Discharge Notice dated 01/29/2018 documented Resident #5 was given a notice that the facility will discharge him on 02/02/2018 to an address mentioned on the form. The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. A review of the Social Work Discharge Plan dated 02/02/2018 documented Resident #5's discharge destination is resident's own home. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 12/07/2017, indicated a BIMS (Brief Interview for Mental Status) score of 13/15, cognitively intact. A review of the Transfer /Discharge Notice dated 01/04/2017 documented Resident #6 was given a notice that the facility will discharge her on 01/08/2017 to (an address mentioned on the form). The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. A review of the Social Work Discharge Plan dated 01/08/2018 documented Resident #6's discharge destination is resident's own home. There was no documented evidence that the facility sent a copy of the Notices of transfer/discharge to the Office of the State Long Term Care Ombudsman. The SW was interviewed on 03/21/2018 at 11:15 AM, and stated that a copy of the Notice given to Resident #1, was not sent to the Ombudsman because it was not a 30-day notice of transfer/discharge. The Director of Social Service (DSS) was interviewed on 04/27/2018 at 9:10 AM via telephone. She stated that a copy of transfer/discharge notice for all mentioned residents was not sent to the Office of the State Long Term Care Ombudsman because the discharges were not involuntary and they were not 30-day notices. 415.3(h)(1)(i)(iii)(a-c)

Plan of Correction: ApprovedMay 25, 2018

F 623 Notice Requirements before Transfer/Discharge
Part 1
The Director of Nursing investigated the case of resident #1 due to the deficiency. The following actions were taken:
Review of the transfer/discharge notifications
Resident #1 was transferred to the hospital and discharged to the community. He no longer resides at the facility.
Resident #2 The discharge was a resident imitated discharge. The resident was given discharge notification and discharged to his former Shelter at Forbells Men?s Shelter in Brooklyn. For resident initiated discharges the notice to the ombudsman is not required.
Resident #3 The discharge was a resident initiated discharge. The resident was given discharge notification and discharged to his former residence at Forbell?s Men?s Shelter in Brooklyn. For resident initiated discharges the notice to the ombudsman is not required.
Resident #4 The discharge was a resident initiated discharge. The resident was given discharge notification and requested not to return to her former shelter in Brooklyn. She was assisted with shelter placement in the Bronx. She was transferred to the Women?s Shelter at the Franklin Ave. For a resident initiated discharges the notice to the ombudsman is not required.
Resident #5 Resident initiated discharge. He planned to return to his home once he completed his therapy. He returned to his home with home care services. For resident initiated discharges the notice to the ombudsman is not required.
Resident #6 Resident initiated discharge. She planned to return to her home once she completed her therapy. She returned home with home care services. For resident initiated discharges the notice to the ombudsman is not required.
The social worker who failed to notify the Office of the State Long Term Care Ombudsman Office of the transfer/discharge has been counselled and educated.
Part 2
The Director of Social Work reviewed all resident Transfers/Discharges for the month of (MONTH) to ensure the NY State Long Term Care Ombudsman Office was notified in accordance with Transfer/Discharge Right and Regulation Policy. There were no issues identified.
Part 3
The DNS reviewed the policy Discharge/Transfer Rights and Regulations and has updated the policy to specifically outline when the Long Term Care Ombudsman Office is to be notified of resident transfers.
The In-service Coordinator educated the licensed nursing staff and social workers on the revised policy. A copy of the lesson plan and attendance will be filed for reference and validation
The Director of Social work/Designee will review the 24 hour report daily to ensure the NY State Long Term Care Ombudsman Office was notified in accordance with Transfer/Discharge Right and Regulation Policy.
Part 4
The Director of Social Work will audit all Transfers and Discharges to ensure appropriate notification of the NY State Long Term Care Ombudsman Office weekly for 4 weeks and monthly thereafter for three months or longer until 95% compliance is achieved.
The findings of the audits will be presented to the Administrator on a monthly basis for three months and to the QA/QI committee at its quarterly meeting for evaluation and follow up as indicated. At the end of the three month period the QA/QI Committee will determine the need for on-going auditing and additional corrective actions if necessary.
Any quality issues identified as part of this overall review will have corrective actions implemented and documented for validation



FF11 483.24:QUALITY OF LIFE

REGULATION: § 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 8, 2018
Corrected date: May 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (NY 727), the facility did not ensure that a resident received the necessary care and services to maintain the highest practicable well-being in a timely manner for 1 out of 6 residents sampled (Resident #1). Specifically, Resident #1 was assessed on 01/31/2018 with redness, swollenness and tenderness to the left hip surgical site and the Nurse Practitioner (NP) was made aware. Record review revealed that no interventions were implemented on 01/31/2018. Resident #1's primary physician was informed on 02/01/2018 at 9:40 AM and ordered Antibiotic treatment. Subsequently, Resident #1 was transferred to the hospital on [DATE] at 11:30 AM and was given a dose of Intravenous Antibiotics in the Emergency Department (ED) for the [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) on 01/23/2018, indicated a Brief Interview for Mental Status (BIMS - used to determine attention, orientation and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). A Nurse's Progress Note, (by Registered Nurse #1) RN #1, dated 01/31/2018 at 5:32 PM documented that Resident #1's left hip incision site was noted with [DIAGNOSES REDACTED] and tenderness to the distal part of the incision site. The site was intact and without any drainage. The Nurse Practitioner (NP) was notified regarding the surgical incision status. There was no documentation of interventions implemented. A Rehab Progress Note by the Physical Therapist (PT), dated 01/31/2018 at 08:21 PM, documented that on observation, Resident 1's left hip surgical site appeared swollen, red, tender and warm to touch. The Nurse Manager and the Social Worker (SW) were informed. A Nurse's Progress Note, (by RN #1), dated 02/01/2018 at 09:40 AM documented that she spoke with the physician regarding Resident #1's left hip surgical incision site. The physician ordered Keflex 500 milligrams (mg) twice a day for 7 days. An Order Summary Report dated 02/01/2018 - 02/28/2018 documented, Keflex Capsule 500mg, give 500mg by mouth two times a day for [MEDICATION NAME], for left hip surgical wound for 7 days. A Situation, Background, Appearance, Request or Recommendation (SBAR) tool dated 02/01/2018 at 10:58 AM, (by RN #2), documented that Resident #1 had infection to his left hip surgical site which started on 02/01/2018 at 10:00 AM. The tool also documented that Resident #1 was started on Keflex. At 10:00 AM, the physician recommended to transfer Resident #1 to ED. A Medication Administration Record [REDACTED]. A Nurse's Progress Note, (by RN #2), dated 02/01/2018 at 3:26 PM documented that Resident #1 was transferred to the hospital on [DATE] at 11:30 AM with the [DIAGNOSES REDACTED]. A hospital document dated 02/01/2018 documented that Resident #1's chief complaint by Emergency Medical Services (EMS) was infection to left hip surgical site. The Emergency Department (ED) physician's note dated 02/01/2018 documented no discharge or palpable abscess along incision. [MEDICAL CONDITION] approximately 10 cm diameter spanning the inferior aspect of incision. Resident #1 received a dose of Intravenous Antibiotic and labs were ordered. Resident #1 was discharged from the hospital with the [DIAGNOSES REDACTED]. A prescription was given for oral [MEDICATION NAME]-Clavulanate and Bactrim DS and Resident #1 to follow up with Ortho Surgeon. The PT was interviewed on 03/21/2018 and 05/08/2018, and stated that on 01/31/2018, the resident complained that his left hip was red and swollen. She also stated that the resident showed her the left hip surgical site on 01/31/2018 at approximately 2:00 PM and she notified the nurse and Rehab Director. RN#1 was interviewed on 03/22/2018 at 11:43 AM via telephone and stated that she notified the NP on 01/31/2018 (does not remember time) after she observed Resident #1's left hip surgical site with redness and swollenness. She also stated that she notified the physician on 02/01/2018 regarding redness on Resident#1's left hip surgical site and an order for [REDACTED]. The NP was interviewed on 05/04/2018 at 11:25 AM via telephone, and stated he reviewed Resident #1's medical record and does not recall Resident #1 and does not recall speaking with the RN. He further stated that if he did, he would have documented his interventions in the resident's medical record. RN #2 was interviewed on 03/21/2018 at 12:07 PM, and stated that she assessed Resident #1's left hip surgical site on 02/01/2018 and that it was swollen and red. She stated that the physician ordered for the resident to be transferred to the hospital for further evaluation. Resident #1's primary physician was interviewed on 03/22/2018 and 04/26/2018 via telephone. He stated that on 02/01/2018, a nurse called him regarding Resident #1's complaint of pain and [DIAGNOSES REDACTED] at the surgical site. The physician further stated that the site had signs of possible infection and that he gave an order for [REDACTED]. The Director of Nursing Services (DNS) was interviewed via telephone on 05/08/2018 at 11:15 AM, and stated that she was not aware that RN#1 spoke with the NP on 01/31/2018 regarding [DIAGNOSES REDACTED] and swollenness to Resident 1's left hip surgical site. She also stated that she was not aware that there were no interventions implemented after the NP was notified. 415.12

Plan of Correction: ApprovedJune 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F675 Quality of Life
Part 1
The Director of Nursing investigated the case of resident #1 due to the deficiency. The following actions were taken: Resident #1 is no longer resides at the facility. The Nurse Practitioner who failed document an intervention for the surgical incisions is no longer at the facility.
Part2
All residents have the potential to be affected.
Part3
The Medical Director/Designee will educate the medical providers on the importance of timely documentation and treatment of [REDACTED].
The Director of Nursing/Designee will review the 24 hour report daily with the medical director to ensure residents who are exhibiting signs of infections are evaluated by the medical provider and appropriate treatment is ordered, as indicted.
The Medical Director will educate the medical providers on timely documentation of changes in condition. A copy of the lesson plan and attendance will be filed for reference and validation
Part4
.The Medical Director/Designee will conduct an audit to ensure timely documentation of changes in condition and appropriate treatment is ordered, as indicated weekly for four weeks and monthly thereafter for three months or longer until 95% compliance is achieved.
The findings of the audits will be presented to the Administrator on a monthly basis for three months and to the QA/QI committee at its quarterly meeting for evaluation and follow up as indicated. At the end of the three month period the QA/QI Committee will determine the need for on-going auditing and additional corrective actions if necessary
The Nurse Educator/Designee will educate the Nursing staff on timely documentation of changes in condition. A copy of the lesson plan and attendance will be filed for reference and validation
The Nurse Director/Designee will conduct an audit to ensure timely documentation of changes in condition and appropriate treatment is ordered, as indicated weekly for four weeks and monthly thereafter for three months or longer until 95% compliance is achieved.
The findings of the audits will be presented to the Administrator on a monthly basis for three months and to the QA/QI committee at its quarterly meeting for evaluation and follow up as indicated. At the end of the three month period the QA/QI Committee will determine the need for on-going auditing and additional corrective actions if necessary
Any quality issues identified as part of this overall review will have corrective actions implemented and documented for validation



FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 8, 2018
Corrected date: May 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (NY 727), the facility did not ensure that the clinical records of a resident under its responsibility were accurately documented in accordance with accepted professional standards. This was evident for 1 out of 6 residents sampled (Resident #1). Specifically, the Physical Therapist and the Registered Nurse #1 (RN #1) documented in the progress note on 01/31/2018 that Resident #1 had swollenness, tenderness and redness to the left hip surgical site. A Situation, Background, Appearance, Request or Recommendation (SBAR) tool dated 02/01/2018 at 10:58 AM documented that Resident #1 had infection on left hip surgical site that started on 02/01/2018 at 10:00 AM and that Resident #1 was started on Keflex. The Medication Administration Record [REDACTED]. The nursing progress note documented that Resident #1 was transferred to the hospital on [DATE]. However, the Nursing Home to Hospital Transfer Form documented that Resident #1 was transferred to the hospital on [DATE]. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) on 01/23/2018, indicated a Brief Interview for Mental Status (BIMS- used to determine attention, orientation and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). A Nurse's Progress Note, (by Registered Nurse #1) RN #1, dated 01/31/2018 at 5:32 PM documented that Resident #1's left hip incision site was noted with [DIAGNOSES REDACTED] and tenderness on the distal part of the incision. The site was intact and without any drainage. The Nurse Practitioner (NP) was notified regarding the status of the surgical incision. A Rehab Progress Note by the Physical Therapist (PT), dated 01/31/2018 at 08:21 PM, documented that Resident #1 complained of swollenness to his left hip surgical site. Observation of the left hip surgical site revealed that it was swollen, red, tender and warm to touch. A Nurse's Progress Note, (by RN #1), dated 02/01/2018 at 09:40 AM documented that she spoke with the physician regarding Resident #1's left hip surgical incision site and that the physician ordered Keflex 500 milligrams (mg) twice a day for 7 days. An Order Summary Report dated 02/01/2018 - 02/28/2018 documented Keflex Capsule 500mg give 500mg by mouth two times a day for [MEDICATION NAME] for left hip surgical wound for 7 days. A Situation, Background, Appearance, Request or Recommendation (SBAR) form dated 02/01/2018 at 10:58 AM, (by RN #2) documented that Resident #1 had an infection to the left hip surgical site which started on 02/01/2018 at 10:00 AM. The form also documented that Resident #1 was started on Keflex and the physician recommended to transfer the resident to Emergency Department (ED). A Medication Administration Record [REDACTED]. A Nurse's Progress Note, (by RN #2), dated 02/01/2018 at 3:26 PM documented that Resident #1 was transferred to the hospital on [DATE] at 11:30 AM with [DIAGNOSES REDACTED]. The Nursing Home to Hospital Transfer Form documented that Resident #1 was transferred to the hospital on [DATE]. RN#1 was interviewed on 03/22/2018 at 11:43 AM, and stated that she notified the NP on 01/31/2018 after she observed Resident #1's left hip surgical site with redness and swollenness. She stated that the physician was notified on 02/01/2018 and ordered antibiotics. The Director of Nursing Services (DNS) was interviewed on 05/08/2018 at 11:15 AM, regarding the inaccurate documentation. She stated that she was not aware of Resident #1's complaints of redness and swollenness to his left hip surgical site. She also stated that Resident #1 was transferred to the hospital on [DATE], however the transfer form documented the date of transfer as 01/18/2018. She further stated that the RN should have updated the form to reflect the correct date of transfer. She stated that she was unable to find documentation that Resident #1 received the first dose of Keflex prior to transfer to the hospital. 415.22 (a)(1-4)

Plan of Correction: ApprovedMay 25, 2018

F842 Resident Records-Identifiable Information
Part 1
The Director of Nursing investigated the case of resident #1 due to the deficiency. The following actions were taken: Resident #1 no longer resides at the facility. The nurse who recorded the incorrect date on the transfer form was counseled.
Part2
The DNS reviewed all of the E-Interact Transfer forms for the month of (MONTH) to ensure information was accurate. There were no issues identified.
Part3
The DNS reviewed the Hospital Transfer policy and was found to be compliant.
The In-service Coordinator educated the licensed nursing staff on the use of the E-Interact Transfer form and the importance of documenting accurate information on the form. A copy of the lesson plan and attendance will be filed for reference and validation
Part4
The DNS will conduct an audit to ensure the E-Interact From is completed accurately weekly for four weeks and monthly thereafter for three months or longer until 95% compliance is achieved.
The findings of the audits will be presented to the Administrator on a monthly basis for three months and to the QA/QI committee at its quarterly meeting for evaluation and follow up as indicated. At the end of the three month period the QA/QI Committee will determine the need for on-going auditing and additional corrective actions if necessary.
Any quality issues identified as part of this overall review will have corrective actions implemented and documented for validation

FF11 483.15(c)(1)(i)(ii)(2)(i)-(iii):TRANSFER AND DISCHARGE REQUIREMENTS

REGULATION: §483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) 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; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) 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. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §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. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 8, 2018
Corrected date: May 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during an abbreviated survey (NY 727), the facility did not ensure that a resident's physician documented information about the basis for hospital transfer or discharge. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 was transfer/discharge to the hospital on [DATE]. The physician did not document in Resident #1's medical record the reason, specific needs the facility could not meet, the facility efforts to meet those needs and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. A Facility Policy and Procedure titled, Discharge/Transfers Rights and Regulations, dated 03/2017 states that the documentation required must be completed by a physician /Nurse Practitioner (NP) when a transfer or discharge is necessary due to resident's welfare and the resident's needs cannot be met in the facility. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 01/23/2018, indicated a BIMS (Brief Interview for Mental Status) score of 15/15, cognitively contact. A Nurse's Progress Note, (by Registered Nurse #1) RN #1, dated 01/31/2018 at 5:32 PM documented that Resident #1's left hip incision noted with [DIAGNOSES REDACTED] and tenderness on distal part of the incision and that Resident #1 complained pain. The site was intact and without any drainage. The Nurse Practitioner (NP) was notified regarding the surgical incision status. No further documentation noted on 01/31/2018 regarding the left hip surgical site. A Nurse's Progress Note, (by RN #1), dated 02/01/2018 at 09:40 AM documented that she spoke with the physician regarding Resident #1's left hip surgical incision. The physician ordered Keflex 500 milligrams (mg) twice a day for 7 days. An Order Summary Report dated 02/01/2018 - 02/28/2018 documented Keflex Capsule 500mg give 500mg by mouth two times a day for [MEDICATION NAME] for left hip surgical wound for 7 days. A Medication Administration Record [REDACTED]. A Situation, Background, Assessment, Recommendation (SBAR) form dated 02/01/2018 at 10:58 AM, (RN #2), under title Situation documented that Resident #1 had infection on left hip surgical site started on 02/01/2018 at 10:00 AM. The form also documented that Resident #1 was started on Keflex. Resident #1's vital signs documented as Temperature 98 degrees Fahrenheit, Pulse 68, Respiration 18 and Blood Pressure 133/85. Primary physician's recommendation at 10:00 AM to transfer the resident to Emergency Department (ED). An Order Summary Report dated from 02/01/2018 - 02/28/2018 revealed no doctor's order to transfer Resident #1 to the hospital. A Nurse's Progress Note, (by RN #2), dated 02/01/2018 at 3:26 PM documented that Resident #1 was transferred to the hospital on [DATE] at 11:30 AM with [DIAGNOSES REDACTED]. A Transfer /Discharge Notice dated 02/01/2018 documented Resident #1 was given a notice that the facility will discharge Resident #1 (mentioned by name on form) on 02/01/2018 to the hospital. The appropriate reason (checked mark) this transfer/discharge notice is being issued for your welfare as your needs cannot currently be met by the services available at facility, left hip surgical site possible infection. A hospital document dated 02/01/2018 documented that Resident #1 chief complaint by Emergency Medical Services (EMS) was infection to left hip surgical site. The Emergency Department (ED) physician's note dated 02/01/2018 documented no discharge or palpable abscess along incision. [MEDICAL CONDITION] approximately 10cm diameter spanning the inferior aspect of incision. Physician's plan included dose of Intravenous Antibiotic, labs and discharged back to facility with oral antibiotics for two weeks and follow-up with ortho surgeon. Resident #1 was discharged from hospital with [DIAGNOSES REDACTED]. A prescription was given for oral [MEDICATION NAME]-clavulanate and Bactrim DS. A Nurse's Progress Note, (by RN#3), dated 02/02/2018 at 7:00 AM documented that a follow-up disposition call was made to the hospital and was informed by ER nurse that Resident #1 was discharged to the community. A review of the Physician's Progress Notes did not reveal any documented evidence of Resident #1's transfer/discharge. The last entry made by physician was 01/26/2018. In addition, there was no documentation from the NP who was informed on 01/31/2018 regarding Resident #1's surgical site with redness and complaints of pain. RN #2 was interviewed on 03/21/2018 at 12:07 PM, and stated that she assessed Resident #1's left hip surgical site that was swollen and red. She stated that the physician ordered for the resident to be transferred to the hospital for further evaluation. Resident #1's primary physician was interviewed on 03/22/2018 and 04/26/2018 via telephone. He stated that a nurse called him regarding Resident #1's complaint of pain and [DIAGNOSES REDACTED] at the surgical site. The physician further stated that the site had signs of possible infection and that he gave an order for [REDACTED]. He stated that that he did not document because Resident #1 was not discharged and that he gave an order to send the resident to the hospital for an evaluation of the wound infection. The Director of Nursing was interviewed on 04/18/2018 at 3:50 PM via telephone. She stated that the order was documented as a telephone order. The DNS responded to a question regarding physician documentation of a resident transfer/discharge. She stated there was no documentation in the physician's progress notes regarding the resident's basis for transfer. She added that if the physician is in the building during the time of the transfer, then he will write a note, otherwise it will be a telephone order. She further added that the resident's transfer to the hospital was documented by the nurse on the SBAR form. 415.3(h)(1)(ii)(a-c)

Plan of Correction: ApprovedMay 25, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F622 Transfer and Discharge Requirements
Part 1
The Director of Nursing investigated the case of resident #1 due to the deficiency. The following actions were taken:
Resident #1 no longer resides at the facility.
The physician who failed to document in the medical record of the Resident #1 was counsel on appropriate documentation when transferring or discharging a resident from the facility.
The Nurse Practitioner who failed to document changes in the surgical incision on 1/31/18 is no longer at the facility.
The licensed nurse who failed to document an order for [REDACTED].
Part 2
The Director of Social Work reviewed all resident Transfers/Discharges for the month of (MONTH) to ensure the NY State Long Term Care Ombudsman Office was notified in accordance with Transfer/Discharge Right and Regulation Policy. There were no issues identified.
Part 3
The DNS reviewed the policy Discharge/Transfer Rights and Regulations and has updated the policy to specifically outline when the Long Term Care Ombudsman Office is to be notified of resident transfers.
The In-service Coordinator educated the licensed nursing staff and social workers on the revised policy. A copy of the lesson plan and attendance will be filed for reference and validation
The DNS reviewed the Hospital Transfer policy and was found to be compliant with regulation with respect to the need for a physician order [REDACTED]. A copy of the lesson plan and attendance will be filed for reference and validation
The DNS reviewed the policy MD Transfer and Discharge Summary and was found to be compliant with the regulation. The Medical Director educated the medical providers on the policy. A copy of the lesson plan and attendance will be filed for reference and validation

F622 Transfer and Discharge Requirements con?t
Part 4
? The Director of Social Work will audit all Transfers and Discharges to ensure appropriate notification of the NY State Long Term Care Ombudsman Office weekly for 4 weeks and monthly thereafter for three months or longer until 95% compliance is achieved. Results of the audits will be reported to the Quality Management Committee.
? The DNS will conduct an audit to ensure orders for transfer to the acute care hospital are entered by the nurse/medical provider daily for four weeks and monthly thereafter for three months or longer until 95% compliance is achieved. Results of the audits will be reported to the Quality management Committee.
? The Medical Director/designee will audit the completion of the Discharge/Transfer form by the medial providers on a weekly basis for 4 weeks and monthly thereafter for three months or longer until 95% compliance is achieved. Results of the audits will be reported to the Quality management Committee.
? The findings of the audits will be presented to the Administrator on a monthly basis for three months and to the QA/QI committee at its quarterly meeting for evaluation and follow up as indicated. At the end of the three month period the QA/QI Committee will determine the need for on-going auditing and additional corrective actions if necessary.
? Any quality issues identified as part of this overall review will have corrective actions implemented and documented for validation