Other·September 27, 2024

REGULATION VIOLATION T22 DIV5 CH3 ART5 - 72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/27/22, the California Department of Public Health, Field Operations Branch received a complaint related to an unplanned discharge for Resident 1. An unannounced visit to the facility was conducted on 6/28/22 at 10 a.m. to initiate the investigation. The facility failed to provide Resident 1 notice of bed hold prior to hospital transfer as required by policy and did not allow Resident 1 to return to the nursing facility when he was ready to be discharged from the hospital. Resident 1's Face Sheet (A one-page summary of important information about a resident) indicated Resident 1 was initially admitted on 12/4/2019 with a diagnosis including Dementia (disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbance and Post Traumatic Stress Disorder (PTSD - psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event). A licensed nurse's Progress Note for Resident 1 dated 5/18/22 at 2:26 p.m. indicated Resident 1 engaged in a physical altercation with a female resident which resulted to her fall. A licensed nurse's Progress Note for Resident 1 dated 5/18/22 at 10:52 p.m. indicated staff did not observe Resident 1 with any behavior however, Resident 1's roommate reported that Resident 1 was abusive to him. The Progress Note indicated Resident 1 hit his arm days ago and that he felt unsafe around Resident 1. The Progress Note indicated Resident 1 was then sent to the hospital on 5/18/22 at 9:30 p.m. for increased psychosis. The Hospital Discharge Planning/ Admission Assessment form dated 5/18/22 indicated Resident 1 was admitted due to aggressive behavior towards another resident. The Hospital note indicated facility will not accept resident back. The hospital notes also indicated Resident 1 reported he wanted to go back to the facility." The Minimum Data Set (MDS -health status screening and assessment tool used for all residents) discharge assessment for Resident 1, dated 5/18/22 indicated there was no active discharge plan for Resident 1 to return to the community. The MDS indicated Resident 1's return to the nursing facility was anticipated. The Hospital Discharge Planner Note, dated 5/24/22, indicated Resident 1 was medically stable for discharge. The Social Services Note for Resident 1 dated 6/01/22 at 6:20 p.m., indicated the Social Service Director (SSD) took the Skilled Nursing Facility (SNF) discharge packet to the hospital for Resident 1 to sign. The SSD note indicated, "[Resident 1] was compliant with signing the documentation even though he wrote 'no' on the notice of proposed transfer / discharge form." On 6/28/22 at 11:30 a.m., Director of Nursing (DON) A stated they would normally call resident's representative within 24 hour to discuss bed hold policy when a resident was sent to the hospital. DON A stated reason for sending Resident 1 to the hospital was because Resident 1 kicked one female resident out of her wheelchair resulting to an injury. DON A stated Resident 1's doctor stated the facility was not the right placement for Resident 1 and could cause further harm to other residents and to other individuals. DON A stated Resident 1's doctor instructed the facility to not take Resident 1 back until the hospital figured out what was going on with Resident 1. When DON A was asked if this discussion with the doctor was documented in Resident 1's record, DON A stated, "No." DON A stated the facility did not offer bed hold notification to either Resident 1 or his responsible party because there was a confusion whether Resident 1 will be readmitted back to the facility. DON A also stated Resident 1 was already evicted while he was at the hospital; however, Resident 1 won the appeal. On 6/28/22 at 12:17 p.m., SSA (Social Service Assistant) B stated when a resident was sent to the hospital, the Business Office Manager would discuss bed hold policy with either the resident or resident's representative. SSA B stated the Business Office Manager would then let the Social Service know if resident wanted a bed hold or not. Facility policy and procedure titled "Admission/ Discharge/Transfer: Bed Hold" revised in 11/2016 indicated," The resident, or the resident's representative, shall be informed, in writing, of the right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital or for therapeutic leave." Review of the Facility policy and procedure titled "Admission, Discharge, Transfer: Criteria for Transfer and Discharge" revised in 11/2016 indicated: " It is the policy of this Facility that each resident will remain in the Facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria." Facility procedures indicated, a. "If the resident exercises his or her right to appeal a transfer or discharge notice, the Facility shall not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the Facility. The Facility shall document the danger that failure to transfer, or discharge would pose." b. "If the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility, the resident's physician shall document the following in the resident's medical record: 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)." c. "A physician shall document if the transfer or discharge is necessary because the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident OR because the health of individuals in the Facility would otherwise be endangered." In violation of the above cited standards, facility failed to provide Resident 1 notice of bed hold prior to hospital transfer and failed to allow Resident 1 to return to the nursing facility when he was ready to be discharged from the hospital. Failure to provide a notice of a bed hold did not ensure Resident 1 was notified of his rights to return or how to reserve a bed with payment and failure to allow Resident 1 to return to the facility had the potential to cause Resident 1 emotional and mental stress. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.