New Carlton Rehab and Nursing Center, LLC
February 27, 2019 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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: March 8, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (NY 001), the facility did not ensure that the Office of the State Long Term Care (LTC) Ombudsman was notified of residents' transfers/discharges. This was evident for 3 out of 4 residents sampled (Resident #1, Resident #2 and Resident #3). Specifically, Resident #1, #2 and #3 were transferred to the Hospital and the facility did not notify the Office of the State Long Term Care Ombudsman of the transfers. Review of the facility's Policy and Procedure on Transfer/discharge date d 3/2018 and Bed Reservation Policy dated 07/19/2010, revealed no information regarding notification to the Ombudsman. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Notice of Transfer dated 12/11/2017 documented that Resident #1 will be transferred to the Hospital because the Resident does not want to be in the facility. A Social Service Closing Summary dated 12/11/2017 documented that Resident #1 was admitted to facility on 12/08/2017 and on 12/11/2017 the Resident was transferred to the Hospital. Resident #2 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 12/21/2017 documented that Resident #2 had short -term memory problem. A Notice of Transfer dated 02/07/2018 documented that Resident #2 was transferred to the Hospital due to wound progression and general decline in weight. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that Resident #3 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) and scored 6/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). A Notice of Transfer dated 12/04/2017 documented that Resident #3 was transferred to the Hospital from the [MEDICAL TREATMENT] Center due to [MEDICAL CONDITION]. Facility had no record or logs to ensure that the State Ombudsman was notified of Residents transfer/discharge to acute care facility. The Director of Social Service (DSS) was interviewed on 11/29/2018 at 2:00 PM and stated that the facility does not notified the Ombudsman if a resident is transferred to a Hospital. Notification of discharge is done only if a Resident is discharged to the community. DSS stated that she does not keep log or document when the Ombudsman is notified. 415.3(h)(I)(iv)(a-e)

Plan of Correction: ApprovedMarch 18, 2019

Element #1. Resident was transferred back to originating hospital due to ?behavior injurious to self or others.? The behavior in question was disrobing in public areas. This behavior was emotionally troubling to visitors and other residents. In addition, resident was a danger to himself in his attempts to elope via the front door. The facility should have, but did not notify the office of the ombudsman. Facility will send notice to ombudsman in the future for all facility initiated transfers as well as a monthly listing of all discharges to acute care facility.

Element #2- Any resident who is a potential for discharge, could be potentially affected by this deficient practice. None were identified.
Element #3- A baseline care plan is required within 48 hours of admission. However, for patients admitted on Thursday or Friday, a baseline care plan, including discharge care planning will be addressed sooner which may be earlier than 48 hours. All members of CCP team including physicians, were In-Serviced regarding the Discharge/transfer requirements and the applicable possible reasons for discharge. Policies for Transfer/Discharge requirements were updated to reflect the regulatory changes. An audit of discharges for the past 60 days will be conducted to ensure that an appropriate reason for discharge has been indicated. An audit of documentation and care planning will be conducted for all residents who are coded through their most recent MDS Assessment as triggering for Mental Status/Psychosocial Well-being to ensure documentation reflects any behavioral issues. These audits will be utilized as part of the in-service training for staff. Ombudsman will be notified of all facility initiated transfers and will receive a monthly listing of all transfers for acute care.
Element#4- In addition to all of the required notifications to the Health Department, resident and NOK, as per requirement, the Ombudsman will be notified whenever a 30-day notice of intent to discharge is given to a resident. Ombudsman will also be notified monthly of all acute care discharges.
The Social Work Department will maintain a log of all discharges initiated by facility. As per Office of the Ombudsman, it is acceptable to send a monthly log indicating all transfers and the facility will immediately put this practice into effect. All discharges are discussed at the Morning Meeting which occurs Monday thru Friday morning. This morning meeting constitutes on-going reporting to the QA Committee and a formal report will be made quarterly. In addition, any discharges on weekends will be discussed with Medical Director and/or Director of Nursing designee to ensure that the rationale for discharge is appropriate within the requirements. All discharges including the reason for discharge for the previous quarter will be discussed at the quarterly QAPI meeting.
The results of the 60-day discharge audit and the documentation audit for recent MDS Assessment as triggering for Mental Status/Psychosocial Well-being will be reported at the next QAPI meeting.
Element #5- The Administrator will be responsible to ensure that the tracking of discharges and reporting to Ombudsman is current, accurate and monitored through QAPI.

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: February 27, 2019
Corrected date: March 8, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (NY 001), facility did not ensure that a resident receive appropriate discharge. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 was admitted to the facility from a Hospital Upstate New York on 12/08/2017. Facility discharged the Resident #1 back to the same hospital on [DATE], becasue the resident expressed on a communication board, HOME. A facility Policy and Procedure Transfer and Discharge dated 3/2018 documented that the Medical Doctor (MD) discharge summary must justify why resident's needs could not be met. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission assessment dated [DATE], revealed that Resident #1 was non-verbal and communicates by sign/sounds. The Resident understands verbal communication. A Nursing Note (by Nurse Supervisor) dated 12/11/2017 at 1:52 PM, documented that Resident #1 does not want to be here no more, wants to back upstate where he lives and the MD was notified. Resident will be transported to the Hospital, spoke with case manager that the Resident was coming back today. A Discharge Summary, by MD, dated 12/11/2017 documented that the reason for Resident #1's discharge was that Resident wanted to go back to the Hospital. Resident #1 expressed on a communication board home, he did not express Hospital. A Notice of Transfer dated 12/11/2017 documented that Resident #1 will be transferred to Hospital; Resident does not want to remain in our facility. A Patient Transfer Form dated 12/11/2017, revealed that the Resident primary [DIAGNOSES REDACTED]. A Social Service Closing Summary dated 12/11/2017, documented that Resident #1 was admitted to facility on 12/08/2017 and returned to the hospital on [DATE] at his request. A Nursing Progress Note, by Director of Nursing (DON), dated 12/12/2017 at 1:53 PM, documented that Resident #1 was admitted on [DATE] at 10:15 PM. Over the weekend the Resident was ok. On 12/11/2017 the Resident was using communication board to express that he did not want to be in the facility and he wants to go home. The Resident repetitively pointed to his communication board HOME. Resident repetitively ring the bell and staff repeatedly go back to the room and find Resident with his hand in his pants. If the Resident remained in the facility, it would be difficult to redirect him as the Resident became familiar with the primary exit and behaviors expressed were to leave unaccompanied. Review of the Nursing Notes from 12/08/2017 to 12/11/2017, revealed no documentation that the Resident expressed wanting to be transferred back to the Hospital or was displaying inappropriate behavior. A Care Plan for Mental Status/Behavior/Psychosocial Well-being, initiated on 12/08/2017, revealed no documentation to reflect that Resident #1 displayed inappropriate behavior. The DSS was interviewed on 11/29/2018 at 2:00 PM and stated that she interviewed Resident #1 on 12/11/2017. Resident #1 was unable to speak but wrote on a communication board that it was too far and that he wanted to go home. She did not explore discharge options with Resident #1, she assumed that the Resident wanted to go back to the Hospital. The Director of Nursing (DNS) was interviewed on 11/29/2018 at 2:33 PM and stated that she became aware of the Resident on 12/11/2017 (Monday). The Supervisor notified her that the Resident expressed that he wanted to go home. The Resident did not want to be in the facility because it was too far from his home. The Resident was admitted on [DATE] and on 12/11/2017 he was displaying social inappropriate behavior. The facility decided to send the Resident to the Hospital to prevent him from leaving the facility unassisted. A follow- up interview was conducted with the DSS on /02/19/2019 at 1:20 PM. She stated that on 12/11/2017, since Resident #1 wanted to go home, the decision was made to send the Resident to the Hospital because he was in the facility for less than 72 hours. Upon inquiry, the DSS was not able to explain why Resident #1 was not provide with discharge options. She further stated that the Hospital did not provide facility with all Resident #1's medical and social history. Per the DNS's note of 12/12/2017, the facility does not have a policy/procedure to discharge a Resident back to original facility within 72 hours. A follow-up interview was conducted with the DNS on 02/19/2019 at 3:30 PM. She stated that the staff has knowledge on how to handle Residents with behavioral problems. A Resident would be transferred to the Hospital, only if the Resident is a danger to self and others. The main reason for Resident #1's transfer to the Hospital was that the Resident did not want to stay in the facility. The Administrator was interviewed on 02/20/2019 at 4:00 PM and stated that the Social Workers (SW) are responsible for discharge planning and that he oversees the SW's to ensure appropriate discharge is done. He was aware of Resident #1's discharge and that transferring the Resident to the Hospital was appropriate. The MD was interviewed on 02/20/2019 at 10:00 AM and stated that he was not present in the facility when Resident #1 was discharged . The Nursing Supervisor notified him over phone that the Resident insisted on going back upstate. MD stated that the decision to transfer Resident #1 to the Hospital was reasonable as the Resident wanted to leave, had no relatives in Brooklyn and was homeless. The facility had no place to send him except to the Hospital that he was admitted from. 415.3 (h)(1)(ii)(a)(b)

Plan of Correction: ApprovedMarch 18, 2019

Element #1. Resident was transferred back to originating hospital due to ?behavior injurious to self or others.? The behavior in question was disrobing in public areas. This behavior was emotionally troubling to visitors and other residents. In addition, resident was a danger to himself in his attempts to elope via the front door. Despite an educated staff regarding dealing with elopement attempts, this resident was extremely difficult to redirect. All departments, particularly nursing, medicine and Social Work were Re-In-Serviced regarding the need to properly document these types of behaviors. In this particular case the behaviors in questions were not documented well. The patient did, in fact, talk about wanting to return ?home.?
However, that was not the reason patient was transferred. The behaviors in question that appeared to put himself and others in danger were not documented well. The transfer back to the originating facility, we believe, was appropriate though it is difficult to ascertain this due to the lack of appropriate documentation. With regard to how the facility will correct the deficiency as it relates to this individual, the facility cannot retrospectively document the behaviors that led us to the conclusion that this residents behavior was a danger to others.
In addition, the resident, though this was not documented well, was not amenable to, nor a candidate for any type of discharge planning. The resident was adamant about wanting to return to the geographic location that he was familiar with. The action taken by the facility was the safest and most appropriate given the circumstances, however, the documentation did not substantiate this. The immediate correction is to ensure that in similar cases documentation is concise and all encompassing to substantiate these types of decisions.

Element #2- Any resident who is a potential for discharge, could be potentially affected by this deficient practice. None were identified.
Element #3- A baseline care plan is required within 48 hours of admission. However, for patients admitted on Thursday or Friday, a baseline care plan, including discharge care planning will be addressed sooner which may be earlier than 48 hours. All members of CCP team including physicians, were In-Serviced regarding the Discharge/transfer requirements and the applicable possible reasons for discharge. Policies for Transfer/Discharge requirements were updated to reflect the regulatory changes. An audit of discharges for the past 60 days will be conducted to ensure that an appropriate reason for discharge has been indicated. An audit of documentation and care planning will be conducted for all residents who are coded through their most recent MDS Assessment as triggering for Mental Status/Psychosocial Well-being to ensure documentation reflects any behavioral issues. These audits will be utilized as part of the in-service training for staff.
Element#4- All reasons for transfer/discharge will be communicated to receiving facility.
All discharges will be discussed at the Morning Meeting which occurs Monday thru Friday morning.
The discharge summary will be reviewed to ensure all requirements are met regarding notifications and reason for discharge.
This morning meeting constitutes on-going reporting to the QA Committee and a formal report will be made quarterly. In addition, any discharges on weekends will be discussed with Medical Director and/or Director of Nursing designee to ensure that the rationale for discharge is appropriate within the requirements. All discharges including the reason for discharge for the previous quarter will be discussed at the quarterly QAPI meeting.
The results of the 60-day discharge audit and the documentation audit for recent MDS Assessment as triggering for Mental Status/Psychosocial Well-being will be reported at the next QAPI meeting.
Element #5- The Administrator will be responsible to ensure that all requirements are met regarding notifications and communications to the receiving facility regarding specific needs that could not be met.