Other·May 3, 2024

REGULATION VIOLATION(S) § 483.15(e)(1)(2) Permitting residents to return to facility A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident- (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. The facility failed to follow its own policies & procedures when one of three sampled residents (Resident 1) was not allowed to return to the facility, after being taken into police custody for a few hours, without any prior notices of pending discharge. As a result, Resident 1 was hospitalized twice, and left homeless without health care services, medications, shelter, or food, placing his life at serious risk for harm and death. An onsite visit was conducted on 2/10/22, to investigate the incident. Record review revealed Resident 1 was admitted to the facility on 1/29/21, with medical diagnoses including Type 2 Diabetes Mellitus (A chronic disease characterized by high levels of sugar in the blood) with circulatory complications, and Encounter for Orthopedic Aftercare following Surgical Amputation (The removal of a limb by surgery), according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Set-An Assessment tool) dated 2/22/22, indicated his BIMS (Brief Interview of Mental Status-A Cognition assessment) score was 15, which indicated his cognition was intact. Record review of a Health Status Note dated 1/19/22 at 7:44 p.m., indicated, "Resident [Resident 1] picked up [From the nursing facility] and escorted by 6 [Name of city] Police officers around 1:50 PM today." During a phone interview with Witness AA on 2/09/22 at 9:00 a.m., he stated Resident 1 called him from a supermarket parking lot the evening of 1/19/22, after he was released from police custody. Witness AA stated Resident 1 was taken into police custody because he had an outstanding warrant for failure to appear in court in another county but was released by police the same day. Witness AA stated he met with Resident 1 at a supermarket parking lot, and noticed Resident 1 had no medications, no meals, and his wheelchair, which the facility had provided, did not have rubber in one of the wheels, therefore Resident 1 could not move well with it. Witness AA stated he went immediately to the facility and found out facility staff had been instructed not to accept Resident 1 back. During a concurrent observation and interview with Resident 1 on 3/09/22 at 1:10 p.m., he confirmed Witness AA's story and stated that after meeting with Witness AA at the supermarket parking lot, he wheeled himself (using his wheelchair) back to the facility on his own, at nighttime, a process which took him 2.5 hours. Resident 1 was observed during the interview, with below the knee amputations on both legs, sitting in his wheelchair. Resident 1 stated he got back to the facility at approximately 5 a.m., in the morning of 1/20/22, and entered the building. According to Resident 1, he was in his room at the Skilled Nursing Facility (SNF) when police showed up [The facility had called the police] and told him he needed to leave. Resident 1 stated he was hurting, "real bad," and decided to call an ambulance because he could not be left in the cold. During a phone interview with the Administrator on 3/17/22 at 10:36 a.m., he confirmed the Director of Nursing (DON) called the police after Resident 1 showed up at the facility on 1/20/22. He stated the facility had been instructed by the police officers who arrested Resident 1 on 1/19/22, to call the police again if he went back. The Administrator stated Resident 1 wanted to go to a Hospital when police arrived. Record review of a Social Services Note dated 1/20/22 at 12:34 p.m., indicated, "Since it was an arrest (Police took Resident 1 into custody on 1/19/22, for having an outstanding warrant after failing to appear in court in another county), he [Resident 1] was discharged when the police took him from our facility, we cannot take him back and Admin (Administrator), DON, Nursing, entire IDT (Interdisciplinary team) is aware." This note was written by the Social Services Director (SSD). First Hospitalization: Record review of Physician Progress Notes dated 1/21/22 at 10:18 a.m., of the General Acute Care Hospital (GACH) Resident 1 was transferred to on 1/20/22, after he called an ambulance, indicated, "54M (54-year-old man) with history of PTSD (Post Traumatic Stress Disorder-A mental health disorder that some people develop after they experience or see a traumatic event) ...bilateral BKA (Below the knee amputations) ...presents to [GACH] ER (Emergency Room) after being discharged from his skilled nursing facility." Record review of a note written by a Licensed Clinical Social Worker at the GACH, dated 1/22/22 at 1:39 p.m., stated, [Resident 1] is homeless ...He has been resident at [SNF] since January 2021. [Director of Business Development] in admissions at [SNF] informed SW (Social worker) he [Resident 1] was told he was discharged from their facility." During an interview with the Director of Business Development on 3/09/22 at 12:45 p.m., she confirmed she told the GACH Licensed Clinical Social Worker, Resident 1 had been discharged from their facility, as the interdisciplinary team from the facility had informed her of this. The Director of Staff Development did not specify what staff made up the interdisciplinary team. Record review of a note written by a Licensed Clinical Social Worker at the GACH, dated 1/24/22 at 3:02 p.m., indicated Resident 1 was discharged from the GACH to a Motel with services set up with assistance from a community-based program. Record review of a document from the State of California Department of Health Care Services, titled, "BEFORE THE STATE OF CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES OFFICE OF ADMINISTRATIVE HEARINGS AND APPEALS," dated 2/07/22, indicated a representative from the county Long-Term Care Ombudsman Program, filed an appeal on behalf of Resident 1 for his involuntary discharge from the facility. This document indicated, "On January 19, 2022, Resident [Resident 1] was taken into custody by the [Police Department] for an outstanding warrant. On January 20, 2022, Resident returned to Facility but was refused readmission ...Facility did not provide to the resident a copy of the notice of transfer/discharge, medical records, or the documents that reflect discharge planning that it was relying on in the hearing before January 25, 2022, ...During the hearing, [Administrator] testified Facility did not issue Resident a written notice for the discharge of Resident. For the reasons stated above, for the purposes of this hearing, Facility has failed to meet the requirements to involuntarily discharge Resident ...Facility did not meet the requirements to involuntarily discharge Resident. Therefore, the discharge [On 1/19/22] in this case is improper and resident shall be permitted to return to Facility." A form of this document titled, "Certification of Compliance," indicated, "Facility was served the hearing decision on the following date: 2/07/22," yet the facility failed to comply with this hearing decision on 2/09/22 when Resident 1 returned to the facility (below). Record review of a Health Status Note dated 2/09/22 at 2:38 p.m., indicated, "When I [Licensed Nurse writing this note] came to work this AM (Morning) EX-resident [Referring to Resident 1] was sleeping at front door partially blocking entrance with belongings spread out around him. When I informed him that he could not stay there he became upset and abusive. I informed him he needed to leave the property ...I informed him that I was going to call the police. I exited the situation and called [Police Department]. [Police Department] later showed up and escorted him off the property." Second Hospitalization: During an interview with Resident 1 on 3/09/22 at 1:15 p.m., he confirmed he went back to the facility the night of 2/09/22, and again, facility staff left him outside the building without medications, or food. Resident 1 stated another resident of the facility provided him with some blankets. In the morning of 2/09/22, according to Resident 1, staff called the police on him again, and he decided to call an ambulance. Record review of Physician Progress Notes from the GACH (Same GACH Resident 1 was admitted to on 1/20/22) dated 2/09/22 at 11:34 p.m., indicated Resident 1 was readmitted to the GACH on 2/09/22. This document indicated, "He reported he has been compliant with his medications but has missed his doses last night and today due to encounters with law enforcement yesterday and today. He had been panhandling for money to pay for additional days in the hotel but has now run out of money... He slept outdoors (Note did not specify what doors) last night. He called EMS (Emergency Medical Services) today to take him to the ER as he didn't know what else to do." Record review of an e-mail the Medical Director sent the Administrator on 2/09/22 at 2:46 p.m., indicated, "The physicians are very reluctant to re-admit [Resident 1] who was last at our SNF on Jan 19, 2022, at which time he was admitted to [GACH]... The attending staff agrees that we should not take him back until he has had the benefit of an inpatient admission with full psychiatric evaluation." During a phone interview with the Medical Director on 3/16/22 at 5:13 p.m., he confirmed he made the recommendation not to readmit Resident 1 without a psychological assessment (Performed outside the skilled nursing facility) and in stable condition. The Medical Director stated Resident 1 had an aggressive and disruptive behavior. During an interview with the SSD on 2/10/22 at 3:15 p.m., she stated Resident 1 was not considered discharged from the facility, however, the facility could not accept him back from the street without an assessment. This contradicted her note written on 1/20/22 at 12:34 p.m., which indicated, "Since it was an arrest, he [Resident 1] was discharged when the police took him from our facility, we cannot take him back and Admin, DON, Nursing, entire IDT is aware." During another interview on 2/10/22 at 3:20 p.m., the SSD stated the facility physician would not admit Resident 1 back without being assessed in a GACH. She also stated she could not understand why they lost the appeal since they never truly discharged Resident 1 from the facility. She confirmed Resident 1 was not provided discharge notifications, or documents regarding the discharge. During an interview with Resident 1 on 3/09/22 at 1:20 p.m., Resident 1 stated he spent $1,500 of his money while outside the SNF on hotels and food from 1/24/22 to 2/09/22. He also stated he had lost several items that were left in the SNF upon his initial arrest, including a TV, laptop, and prescription eyeglasses. Resident 1 stated he felt neglected, abused, and discriminated against. Record review of the facility policy titled, "Bed Hold," last revised in July of 2017, indicated, "Upon admission, the Facility advises residents and/or their representatives in writing that the Facility has a bed hold policy and will hold the resident ' s bed for up to seven (7) days if the resident is transferred to an acute care hospital or goes on therapeutic leave (Leaving the facility for non-medical reasons)... as long as the resident or his/her representative notifies the Facility within twenty-four (24) hours of the transfer/leave that they wish to have the Facility hold the resident's bed." Record review of the facility policy titled, "Discharge and Transfer of Residents," last revised in February of 2018, indicated, "The resident/ resident representative will be provided with Notice of Propose Transfer and Discharge 30 days prior to discharge or as soon as practicable... Upon transfer to the hospital the resident/resident representative will be given an opportunity to execute a Bed Hold... The facility may transfer or discharge a resident with an order from the resident's physician for reason A, B, E and F. A) The discharge is necessary for the welfare of the resident, and needs cannot be met in the facility. B) The resident's health has improved significantly, and services provided by the facility are no longer required... E) The resident failed after reasonable and appropriate notice to pay for their stay in the facility... F) The facility ceases to operate." Therefore, the facility failed to follow its own policies & procedures when one of three sampled residents (Resident 1) was not allowed to return to the facility, after being taken into police custody for a few hours, without any prior notices of pending discharge. As a result, Resident 1 was hospitalized twice, and left homeless without health care services, medications, shelter, or food, placing his life at serious risk for harm and death. This violation presented either imminent danger that serious harm would result or a substantial probability that serious harm would result.