Franciscan Health Indianapolis

“ADMISSION, TRANSFER, AND DISCHARGE RIGHTS CFR(s): §482.58(b)(2) Admission, transfer, and discharge rights (§483.5 definition of transfer and discharge, §483.15(c)(1), (c)(2)(i), (c)(2)(ii), (c)(3), (c)(4), (c)(5), and (c)(7)) • §483.5: definition of transfer and discharge: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. • §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. Non-payment 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)(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). • §483.15(c)(2)(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. • §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 (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)(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. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to complete transfer forms in 2 of 10 (Patient 1 and 4) medical records reviewed. Findings include: 1. Facility policy titled Discharge Planning and Transfer Procedure, PolicyStat ID 18398017, last revised 07/01/2025, Discharge Planning Processes indicated under AA. Assembling Transfer Packet and Completing Patient Transfer Envelope Form: 1. The following is to be completed when patients are transferred to another facility (i.e. new campus location, extended care facility, subacute rehab, acute care hospital etc.):, c. Complete “Authorization for Transfer”, have patient, family, SO (significant other) sign it. 2. Review of patient 1’s medical record (MR) indicated the following: a. The patient was admitted on 07/01/2026 for comprehensive rehabilitation including physical, occupational, and speech therapy. b. On 07/04/2026, P1’s (Nurse Practitioner) note indicated that Facility #2’s (Acute Care Facility) neurosurgery provider requested patient to be transferred to Facility #2. P1 ordered patient’s discharge to another health care facility at 10:42 p.m. MR indicated that patient was discharged at 11:15 p.m. c. Medical record lacked documentation of Authorization for Transfer form. 3. Review of Patient 4’s MR indicated the following: a. The patient was admitted on 07/12/2026 for comprehensive rehabilitation including physical, occupational, and speech therapy. b. On 07/20/2026, MR indicated that patient was discharged to an acute care rehabilitation hospital. c. Medical record lacked documentation of Authorization for Transfer form. 4. Interview with A3 (Administrative Director of Quality) on 08/19/2026 at approximately 3:45 p.m. confirmed the policy indicated that a transfer form should be completed for patients who are transferred to another facility or long term care facility. A3 confirmed patient 1 and patient 4 lacked transfer forms.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to follow policy for patients leaving against medical advice in 1 of 10 (Patient 5) medical records reviewed. Findings include: 1. Facility policy titled Discharge Against Medical Advice and/or Patient Absconded Procedure, PolicyStat ID 18779116, last reviewed 12/2/2025 indicated under Procedure: B. Against Medical Advice (AMA) Discharge: When any patient insists on leaving the hospital AMA, patient care personnel will implement the following interventions. 3. Notify the staff / attending physician / advanced practice provider (APP) if the patient continues to insist on leaving. Every attempt will be made to encourage the patient to wait. The physician / APP may elect to do one of the following: a. Release the patient AMA. and 7. Obtain patient’s signature on the Refusal of Advised Medical Care form, #11-10701. 2. Review of Patient 5’s medical record indicated the following: a. The patient arrived at the emergency department on 10/20/2025 at 6:33 p.m. with a chief complaint of urinary urgency and frequency. b. At 10:16 p.m. P1’s (Physician Assistant) provider note indicated nursing notified provider that patient 5 left AMA and the provider did not speak to the patient about risks of leaving AMA. c. At 10:20 p.m. N3’s (Registered Nurse) note indicated the patient was frustrated with waiting times and wanted to leave; patient given AMA papers to sign and educated on risks of leaving AMA. d. At 10:31 p.m. medical record indicated patient left and was discharged; N3 marked the patient’s disposition as AMA. e. Medical record lacked documentation of the Refusal of Advised Medical Care form. 3. Interview with A4 (Emergency Department Director) on 02/18/2026 at approximately 12:40 p.m. confirmed only providers can counsel patients on the risks of leaving AMA and patient 5’s medical record lacked documentation of the Refusal of Advised Medical Care form.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to document Morse Fall Risk Score assessment upon admission in 5 of 10 (patients 4, 5, 6, 9, and 10) medical records reviewed and failed to document the nurse’s review of the fall risk predictive score on the fall risk assessment in 6 of 10 (patients 2, 3, 6, 8, 9, and 10) medical records reviewed. Findings include: 1. Facility policy titled, Fall Precautions Procedure, PolicyStat ID 17599893, last revised on 07/23/2025, indicated under Risk Assessment: The nurse will assess and/or review fall risk and document interventions at the following times: A. Within four (4) hours of arrival/admission., B. Once per shift with a minimum of twice in a calendar day. 2. Review of patient 2’s medical record indicated the following: a. The patient was admitted on 08/15/2025. b. Medical record lacked documentation of the nurse’s review of the fall risk predictive score on the fall risk assessment on 08/16/2025 night shift and on 08/17/2025 day shift. c. The patient was discharged on 08/18/2025. 3. Review of Patient 3’s medical record indicated the following: a. The patient was admitted on 07/29/2025. b. Medical record lacked documentation of the nurse’s review of the fall risk predictive score on the fall risk assessment on 08/01/2025 night shift, and on 08/03/2025 day shift and night shift. c. The patient was discharged on 08/06/2025. 4. Review of patient 4’s medical record indicated the following: a. The patient was admitted on 07/29/2025. b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission. c. The patient was discharged on 07/31/2025. 5. Review of patient 5’s medical record indicated the following: a. The patient was admitted on 07/26/2025. b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission. c. The patient was discharged on 08/05/2025. 6. Review of patient 6’s medical record indicated the following: a. The patient was admitted on 07/24/2025. b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission. c. Medical record lacked documentation of the nurse’s review of the fall risk predictive score on the fall risk assessment on 07/24/2025 night shift, and on 07/25/2025 day shift and night shift. d. The patient was discharged on 07/26/2025. 7. Review of patient 8’s medical record indicated the following: a. The patient was admitted on 07/31/2025. b. Medical record lacked documentation of the nurse’s review of the fall risk predictive score on the fall risk assessment on 08/02/2025 day shift, on 08/10/2025 day shift, on 08/11/2025 day shift, and on 08/12/2025 day shift and night shift. c. The patient is a current patient. 8. Review of patient 9’s medical record indicated the following: a. The patient was admitted on 07/26/2025. b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission. c. Medical record lacked documentation of the nurse’s review of the fall risk predictive score on the fall risk assessment on 07/29/2025 day shift. d. The patient was discharged on 07/31/2025. 9 Review of patient 10’s medical record indicated the following: a. The patient was admitted on 07/26/2025. b. Medical record lacked documentation of the Morse Fall Risk Score assessment upon admission. c. Medical record lacked documentation of the nurse’s review of the fall risk predictive score on the fall risk assessment on 07/27/2025 day shift, on 07/29/2025 day shift, and on 08/02/2025 day shift. d. The patient was discharged on 08/04/2025. 10. Interview with A2 (Accreditation Specialist) on 08/18/2025 at approximately 6:00 p.m. confirmed the following: a. The nursing fall education indicated inpatient nursing completes the Morse Fall Risk Score for patients within 4 hours of admission. b. Patients 4, 5, 6, 9, and 10’s medical records lacked documentation of the Morse Fall Risk Score upon admission. c. Patients 2, 3, 4, 5, 6, 8, 9, and 10’s Medical record lacked documentation of the nurse’s review of the fall risk predictive score on the fall risk assessment.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to bathe a patient daily, failed to document completed or refused daily bathing and failed to complete and document twice daily dressing changes as ordered by physician for 1 of 10 medical records reviewed. (P1) Findings include: 1. The facility policy titled, “Standard of Care for the Adult Medical Surgical Patient Guideline”, PolicyStat ID 14245172, last revised 9/12/2023, indicated under: Routine Interventions and Reassessment Standards for Medical Surgical Patient: 19. For all MS patients, bathing supplies are to be offered if ambulatory or a bath provided once daily and PRN. Document when completed or “if patient refuses or declines.” Refer to facility level policy. 2. The facility policy titled, “Skin Assessment and Management Procedure”, PolicyStat ID 14879041, last revised 2/5/2024, indicated under Documentation: Document all skin assessments/interventions on electronic/paper/unit specific flowsheet. Epic documentation should follow the identified format: A. Admission skin assessment and management documentation will include: 5. The following categories should be documented for each Wound LDA: b. Wound Assessments Elements to be documented (as applicable): 19. Dressing changed. 3. Review of MR for P1 indicated a prior order dated 7/18/24 at 5:42 pm indicated P1 was to receive twice daily dressing changes to his/her left inner elbow. Provider order dated 7/19/24 at 1:33 pm indicated P1 was to receive twice daily dressing changes to wounds on his/her right Achilles, right posterior calf, and right posterior ankle. P1’s MR lacked documentation of a second dressing change to the left inner elbow, right Achilles, right posterior calf, and right posterior ankle for dates 7/19/24-7/24/24. MR documentation for P1 lacked documented completed bath or refusal for dates 7/20/24, 7/21/24, 7/23/24, and 7/24/24. 4. In interview on 9/3/24 at approximately 1:15 pm with A5 (Nurse Manager) confirmed P1 should have been, but was not offered a bath daily/bathed daily nor were baths charted as completed or refused on 7/20/24, 7/21/24, 7/23/24 and 7/24/24 and should have been. A5 confirmed dressing changes to P1’s left inner elbow, right posterior calf, right Achilles, and right ankle should have been completed twice daily but were not.”