When a long term care resident is transferred from the place they call home into an unfamiliar setting such as an emergency room, psychiatric unit, other skilled nursing facility, assisted living community, or even homeless shelter as a result of a facility-initiated transfer, their experience can be jarring.
In the recent update to the State Operations Manual, the Centers for Medicare & Medicaid Services (CMS) offers specific guidance for handling such transfers.
Here’s how to help provide stability for a resident and ensure compliance with the new regulations when a transfer is necessary to meet a resident’s escalating needs.

Understand the Reasons for Transfer

The reasons for transfer vary greatly; however, federal regulations allow only six reasons for a transfer or discharge:
1. The discharge or transfer is necessary for the resident’s welfare and the facility cannot meet the resident’s needs.
2. The resident’s health has improved sufficiently so that the resident no longer needs the care and/or services of the facility.
3. The resident’s clinical or behavioral status (or condition) endangers the safety of individuals in the facility.
4. The resident’s clinical or behavioral status (or condition) otherwise endangers the health of individuals in the facility.
5. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility.
6. The facility ceases to operate.
These limitations were imposed to protect residents from involuntary discharges, which often lead to transfer trauma, triggering confusion and negative outcomes. To ensure compliance, staff must document evidence-based rationale prior to transferring the resident, especially when the transfer is for the resident’s welfare or because of behavioral concerns.

Capturing Complete Documentation

To the nurse engaged with a resident who it is determined needs transferring, the required documentation can seem unimportant. For example, Mr. Smith has been kicking staff and recently threw food at another resident and threatened to hit her.

After failed interventions, including moving him from the dining room to a quiet room and assessing him for pain and toileting needs, his behavior continued to escalate. The nurse in charge obtained a physician order to send Mr. Smith to an acute care hospital for evaluation. This is a facility-initiated transfer/discharge, which, according to the State Operations Manual, 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” (CMS, 2017, F622).

The nurse caring for Mr. Smith must document her observations that indicate a need for transfer and all interventions attempted before he was sent for evaluation. She must ensure that documentation in the medical record by the physician (or physician extender where applicable by law) clearly reflects why the transfer is needed, what care or services the facility cannot meet, and staff’s attempts to meet his needs per F622 regulations.

The nurse must also ensure the receiving facility is sent enough information to sufficiently care for the patient. Minimally, this includes contact information of the practitioner responsible for the resident’s care; resident representative information, including contact information; advance directive information; all special instructions or precautions for ongoing care, as appropriate; comprehensive care plan goals; all other necessary information, including a copy of the resident’s discharge summary, consistent with §483.21(c)(2) as applicable; and any other applicable documentation to ensure a safe, effective transition.

In cases of emergent transfers, conveying all care plan information to the receiving provider may not be possible. If not, it must be done as soon after the transfer as possible.

Prompt, Appropriate Notification

Discharges require notification beyond the physician. Mr. Smith’s family must be notified as close to the time of discharge as possible; a family member may be able to meet him at the hospital and greatly ease the transition. The following are also required:
  • The resident and the resident’s representative must be notified of the transfer/discharge in writing and in a language and manner they understand as soon as practicable.
  • A copy of the transfer/discharge information must be sent to the state ombudsman’s office; this includes emergency transfers.
  • The medical record should clearly document the date, the time, and the name of the person who was notified of the discharge/transfer.
  • The facility’s written notice for facility-initiated transfers and discharges must include the following:
  • The specific reason for the transfer or discharge;
  • The effective date of the transfer or discharge;
  • The location to which the resident is to be transferred or discharged;
  • An explanation of the right to appeal to the state;
  • The name, address (mail and email), and telephone number of the state entity that receives appeal hearing requests;
  • Information on how to request an appeal hearing;
  • Information on obtaining assistance in completing and submitting the appeal hearing request; and
  • The name, address, and phone number of the representative of the office of the state long term care ombudsman (CMS, 2017, F623).
If Mr. Smith exercises his right to appeal a facility transfer/discharge notice, he may not be transferred/discharged while the appeal is pending, unless the failure to transfer/discharge would endanger the health or safety of him or others in the facility. In that case, facility staff must document the danger that failure to transfer/discharge would pose. (See the State Operations Manual, F622, for more in-depth information on the appeal process.)

Permitting Readmission

Federal regulation indicates that residents must be permitted to remain in the facility and not be transferred/discharged once admitted, except in rare instances (for example, when a crime has been committed). Mr. Smith is sent to the hospital for evaluation; the emergency room (ER) nurse informs facility staff that no acute condition was found and, therefore, he will return.

The nurse should reassess him upon readmission and, based on the assessment, update his care plan and goals. The interdisciplinary team should continue to seek possible causes for his behavior. This may include family interviews.

Ensuring Resident Safety, Stability

When elderly residents are transferred from their familiar nursing facility setting to a less familiar one, it is often stressful and confusing. Mr. Smith, already experiencing behavioral confusion, arrives at the ER and is met by unfamiliar staff members, bright lights, and new noises. Anxiety may overwhelm him, exacerbating his behaviors.

When transfer is necessary, maintaining all practicable stability is vital to resident outcomes. Best practices that can help limit stress on Mr. Smith include talking with him in advance about what he will encounter upon transfer (required under F624), having a family member meet him at the receiving facility, and assuring him that his personal items will be safe and secure while he is away.

The federal regulations’ goal of limiting transfers unless necessary should be one every facility shares; avoidable transfers have been shown to negatively impact residents. When a transfer is necessary, the need must be clearly documented and the transition made as smoothly as possible. Otherwise, a difficult or declining resident may return from the hospital worse off. Training staff on proper protocols for facility-initiated transfers can both limit and ease these transfers.

Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT, is curriculum development specialist with the American Association of Directors of Nursing Services. She can be reached at