AARP and the Long Term Care Ombudsman have indicated to the Centers for Medicare and Medicaid Services (CMS) that there is an issue in the nation that nursing centers are “dumping” patients who complain or have a high cost of care. If your nursing center was surveyed on your discharges, which story would your documentation tell? Would it be a discharge or a “dump”?
The National Ombudsman website states: “Transfer and Discharge continues to be one of the top complaints that ombudsmen report encountering, and these cases can be complex and extremely time consuming. The threat of transfer or discharge from a nursing home can be both frightening and stressful for residents and their families. Too often, a facility may respond to resident’s difficulties or increasing need for care or repeated questions or complaints from family members by transferring or discharging the resident. The Nursing Home Reform Law of 1987 protects residents from involuntary transfer and discharge.” Despite these protections, discharges which violate federal regulations continue to be one of the most frequent complaints made to State Long Term Care Ombudsman Programs. CMS has begun an initiative to examine and mitigate facility-initiated discharges that violate federal regulations.
The facility requirements under 483.15 is that each resident is permitted to remain in the facility and not be transferred or discharged unless: it is necessary for the resident’s welfare and the resident’s needs can’t be met in the facility; the transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; the safety of others is endangered; the health of individuals in the facility would be endangered; the resident has failed, after reasonable and appropriate notice, to pay for or to have paid under Medicaid or Medicare, a stay at the facility or the facility ceases to operate.
The regulation at 42 CFR 483.15 requires that before a facility transfers or discharges a resident, the facility must notify the resident and the resident’s representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must also send a copy of the notice to Ombudsman. Each facility should contact their local Ombudsman office to determine if they want each form or a list monthly.
When the facility transfers or discharges a resident, 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. Documentation must include the basis for the transfer. If it is because their needs cannot be met, the facility must document how they attempted to meet their needs and the need must be able to be met at the receiving facility.
Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, did not originate through a resident’s verbal or written request, and/or is not in alignment with the resident’s stated goals for care and preferences.
Resident-initiated transfer or discharge means the resident, or the resident representative, has provided verbal or written notice of intent to leave the facility. This does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment.
Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. Transfer and discharge includes movement of a resident to a bed outside of the certified facility, whether that bed is in the same facility or not. Transfer and discharge does not refer to movement of a resident within the same certified facility.
When the surveyor is investigating a discharge or transfer, they must ensure the facility has fully evaluated the resident and does not base the discharge on the resident’s status at the time of transfer to the acute care facility. The resident must be re-evaluated if his or her condition improves to return to the nursing center. “The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless….” means that once admitted, for most residents other than short-term rehab residents, the facility becomes the residents’ home. Surveyors must determine whether a transfer or discharge is resident or facility-initiated. The medical record should contain documentation or evidence of the resident’s or resident representative’s verbal or written notice of intent to leave the facility, a discharge care plan and documented discussions with the resident or the representative concerning the discharge plan. In addition, the comprehensive care plan should contain the resident’s goals for admission and desired outcomes,
which should align with the discharge if it is resident-initiated.
If the nursing facility transfers a resident to the hospital and then does not re-admit the resident because they can’t meet his or her needs, the facility would need to issue both transfer and discharge paperwork, as the resident was transferred and then discharged.
The nursing center may develop their own form for the transfer and discharge or they may use the one on the Agency for Health Care Administration’s website. CMS issued S & C 18-08 NH in late December which states, “As part of the effort to fully address facility-initiated discharges that violate federal regulations, CMS will review deficiencies precipitated by facility-initiated discharges. Unless directed otherwise by the CMS Regional Office (CMS RO), State survey agencies must transfer any case involving facility initiated discharge violations to the CMS RO for review where there is placement in a questionable or unsafe setting, where residents remain hospitalized, where there is a facility pattern, or other circumstances that the RO may identify of cases they would like transferred. This does not change any other enforcement policies that identify cases that must be
transferred to the RO. Following review, the ROs may take enforcement action if they deem it is proper.”
Nursing centers should ensure documentation is in place to tell the story that the resident is discharged and not “dumped.” When transferring an individual to the hospital, centers must issue a transfer notice, and if the resident does not return, a discharge notice. Make sure you are sending your list or copies of your notice to Ombudsman.