Health inspection·March 23, 2022

F626 §483.15(e)(1) 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 sent to a General Acute Care Hospital's Emergency Department, and was not allowed to return to the facility without any prior notices of pending discharge. As a result, the General Acute Care Hospital (GACH) had to find another skilled nursing facility to accept Resident 1 for admission, causing stress and frustration to Resident 1. An onsite visit was conducted on 11/03/21 to investigate the incident. Record review indicated Resident 1 was admitted to the facility on 10/18/21 with medical diagnoses including Fracture of Right Humerus (The bone of the upper arm), Chronic Pain Syndrome and Bipolar Disorder (A condition characterized by extreme mood swings that can range from extreme highs (mania) to extreme lows (depression)), according to the facility Face Sheet (Facility Demographic). Record review revealed Resident 1's MDS (Minimum Data Set-An assessment tool) indicated Resident 1 received a BIMS (Brief Interview of Mental Status-A cognition assessment) score of 15, on 10/25/21, which indicated his cognition was intact. Record review of a GACH Discharge Summary (A clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments which serves as a mode of communication between the hospital care team and aftercare providers), dated 10/18/21 at 9:45 a.m., indicated Resident 1 suffered from bipolar disorder, alcohol abuse, homelessness, multiple falls and appeared to have requested to leave a prior skilled nursing facility against medical advice. This Discharge Summary was developed by the GACH that transferred Resident 1 to the skilled nursing facility on 10/18/21. During an interview with the Director of Nursing (DON) on 11/12/21 at 1:30 p.m., she stated she reviewed the Discharge Summary above, for Resident 1, and made the decision to accept him, with collaboration with another staff member, for Resident 1's initial admission to the facility, which occurred on 10/18/21. The DON stated that after reviewing Resident 1's Discharge Summary from the GACH, she expected Resident 1 to be, "Challenging." Record review revealed a nursing note dated 10/18/21 (Day of admission) at 11:27 p.m., indicated, "patient [Resident 1] is demanding for his Oxycodone (A medication used to treat moderate to severe pain). Nurse explained that we are working with the pharmacist for it ...patient is not listening to explanation, he's interrupting the nurse, he is talking and insisting that he wants his medication "NOW!" resident called 911." Record review revealed a nursing note dated 10/20/21 (Two days after admission) at 3:21 p.m., indicated, "[Resident 1] had episodes of verbally aggressive (Sic) and not receptive to education." Record review revealed a nursing note dated 10/25/21 at 7:47 a.m., indicated, "Resident [Resident 1] A/Ox 3 (Alert and oriented for place, person and time), did not sleep last night, calling out of help with no reason whole night, calling inappropriate words to staff, yelling and screaming with all inappropriate words ...Resident lowered himself down and sat on the floor against his bed." During an interview with the DON on 11/12/21 at 2:15 p.m., she stated Resident 1 claimed he had suffered a fall in his room the morning on 10/25/21, and a Certified Nursing Assistant actually found him sitting on the floor. Record review revealed a nursing note dated 10/25/21 at 8:35 a.m., indicated, "Paramedics came, resident called them up himself, picked resident up to ER (Emergency room) for further evaluation. Resident was not receptive to any education and was verbally aggressive, up to threatening staff that he will be suing everyone for not attending to him." Resident 1's care plans, initiated on 10/25/21, the day of discharge, addressed Resident 1's verbally aggressive behavior, anger, threats, and abuse to staff. Resident 1's medical record did not contain care plans regarding the above behaviors when Resident 1 was living at the facility. During an interview on 11/12/21 at 1:30 p.m., the DON confirmed no interventions for aggressive behavior were care planned for Resident 1 until he was discharged from the facility. The DON stated the reason they (facility staff) had not started care plans on these behaviors before was because they felt they could manage Resident 1's behaviors at the facility. When asked what was the point of initiating these care plans on the day of Resident 1's discharge, the DON stated she could not say, since, "Interventions should have been there from the start." Record review revealed ER notes dated 10/25/21 at 9:30 a.m., from the GACH where Resident 1 was transferred to, the morning on 10/25/21, indicated, "Spoke with [Physician A] from [Skilled Nursing Facility]. [Physician A] states staff at rehabilitation facility do not feels safe with this patient and they will not be accepting this patient back at the facility today." Another ER note dated 10/25/21 at 1:00 p.m., stated, "Spoke with [Physician A] again. He is refusing transport back to the patient's care facility as he states his staff does not feel safe with this patient." During an interview with Physician A on 11/03/21 at 3:32 p.m., he confirmed he did not accept Resident 1 after being evaluated in the ER of the GACH. Physician A stated he feared for the safety of his staff, as Resident 1 was threatening them. During an interview on 11/12/21 at 2:32 p.m., the DON stated the facility did not provide Resident 1 with a discharge notice prior to discharging him from the facility. The DON also confirmed they did not involve law enforcement, or notify any advocacy agencies, including the Ombudsman, of Resident 1's aggressive behaviors, prior to discharge. In addition, the DON confirmed that no staff from the facility notified Resident 1 of his being discharged from facility. When asked, if other than verbal threats, Resident 1 had physically abused staff, the DON stated he had not. When asked if Resident 1 had also been aggressive with other residents at the facility, the DON stated he had not. During an interview with Resident 1, on 11/03/21 from 11:15 a.m. to 11:27 a.m., Resident 1 stated he was taken by ambulance to a GACH on 10/25/21 after suffering a fall at the facility while transferring from his bed to his wheelchair. Resident 1 stated that after his evaluation at the ER, he expected a staff from the facility to pick him up, but nobody came. After hours of waiting in the ER, he was told by ER staff that the skilled nursing facility did not accept him back. Resident 1 stated he was "in shock," as well as frustrated and stressed when he was told the nursing facility did not accept him back, as he had all his belongings there, and expected to return. Record review revealed an ER note dated 10/25/21 at 5:35 p.m., indicated, "Briefly, the patient [Resident 1] is a disposition issue when the nursing home that he came from did not want to take him back because of behavioral issues. Arrangements have been made for the patient to go to a new nursing home." The facility policy titled, "Transfer or Discharge Notice," dated January of 2018, indicated, "A resident and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: c. The safety of individuals in the facility is endangered ...The resident and/or representative (sponsor) will be notified in writing of the following information: i. The reason for the transfer or discharge; The effective date of the transfer or discharge ...The name, address and telephone number of the Office of the State Long-term Care Ombudsman." The facility policy titled, "Bed-Holds and Returns," released on January of 2018, indicated, "Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy." Therefore, the facility failed to follow its own policies & procedures when one of three sampled residents (Resident 1) was sent to a General Acute Care Hospital's Emergency Department, and was not allowed to return to the facility without any prior notices of pending discharge. As a result, the General Acute Care Hospital (GACH) had to find another skilled nursing facility to accept Resident 1 for admission, causing stress and frustration to Resident 1. This violation had a direct or immediate relationship to the health, safety, or security of the resident.