Other·May 25, 2022

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # CA00778798. Representing the Department, HFEN #38534. State Citation B was written. F624 §483.15(c)(7) F 624 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. § 72433 (b)(5) (b) Social work services unit shall include but not be limited to the following: (5) Discharge planning for each patient and implementation of the plan. § 72521 (c)(2) (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. § 72527 (e)(2) (e) Patients' rights policies and procedures established under this section concerning consent, informed consent and refusal of treatments or procedures shall include, but not be limited to the following: (2) How the facility, in consultation with the patient's physician, will identify consistent with current statutory case law, who may serve as a patient's representative when an incapacitated patient has no conservator or attorney in fact under a valid Durable Power of Attorney for Health Care. On 3/30/2022, at 11:25 a.m., an unannounced visit was conducted to investigate a complaint that Resident 1, a resident without capacity for healthcare decisions, had signed a discharge against medical advice form and left the facility in the care of a woman of unestablished status and no documented training/education for Resident 1's post-discharge care needs. The facility failed to: 1. Develop and update a comprehensive discharge plan for Resident 1, 2. Provide documented training and education to a responsible party for the post-discharge care of Resident 1, a resident without capacity for healthcare decisions, 3. Develop/implement a policy and procedure for establishment of a patient representative for unrepresented residents, without legal capacity, who wish to refuse further treatment by discharging against medical advice. 4. Follow facility policy and procedure to obtain a physician order for discharge against medical advice. This had the potential to result in physical, emotional, or psychological abuse/neglect for Resident 1, a resident without legal capacity and without a responsible party. A review of Resident 1's "Admission Record," undated, indicated Resident 1 was admitted to the facility on 2/3/22 as his own responsible party, with a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/3/22, reflected a score of three on the Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired; a score of three is an indication of severe cognitive impairment.) A review of Resident 1's physician Capacity Evaluation dated 3/3/22, signed by the physician, indicated "... No, resident does not have capacity to make medical decisions..." During an interview on 3/30/22 at 2:39 p.m., with the Social Worker (SW), SW stated a woman visitor (VIS) arrived at the facility on 3/22/22. SW stated VIS claimed she was Resident 1's daughter, and VIS had been searching for Resident 1 for years. SW stated he had not received any documentation to indicate there was a familial relationship between Resident 1 and VIS. SW stated on 3/22/22, VIS said she wanted to take Resident 1 home with her to live in Texas. SW stated VIS had visited Resident 1 in the facility daily from 3/22/22 until 3/28/22. SW stated on 3/28/22, VIS said she was going home to Texas that day and wanted Resident 1 to go home with her. SW stated, after he spoke with VIS on 3/28/22, SW had informed the Administrator (ADM) and called the ombudsman to inform them of VIS's desire to have Resident 1 accompany her to Texas that day. During an interview on 3/30/22 at 2:13 p.m., with the ADM, the ADM stated she had spoken to her "boss" about VIS's request to leave with Resident 1. The ADM stated her boss called back and said Resident 1 could leave with VIS. The ADM stated she had never received any documentation to establish a familial connection between Resident 1 and VIS, despite ADM asking for VIS to show documentation to demonstrate a familial connection. The ADM stated she had spoken with Resident 1's physician (PHYS) before Resident 1 left the facility, and PHYS had said Resident 1 did not have capacity to sign himself out AMA, and Resident 1 should not be discharged to VIS's care. During a telephone interview on 3/30/22 at 3:33 p.m., with PHYS, PHYS stated he had spoken with ADM and told the ADM Resident 1 could not sign the form for discharge AMA because Resident 1 had dementia and was not able to make medical decisions for himself. PHYS stated he stated he did not want Resident 1 discharged into the care of the person who alleged she was Resident 1's daughter because there was no evidence to show the alleged relationship existed. PHYS stated he had verbally ordered the DON to not allow Resident 1 to discharge AMA. During an interview on 3/30/22 at 6:00 p.m., with the DON, the DON stated PHYS had given her a verbal order to not discharge Resident 1. The DON stated she had not documented the verbal order and had allowed Resident 1 to leave the facility because an order for discharge was not necessary for a discharge AMA. The DON stated she had been present at the time of Resident 1's discharge and he had not been provided any medications for post-discharge needs because he left AMA. During an interview on 4/13/22 at 11:25 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the ADM and SW had asked her to give the AMA form to Resident 1 to sign. LVN 1 stated the ADM, SW, VIS, and Resident 1 were present in the same room when she gave Resident 1 the AMA form. LVN 1 stated Resident 1 said he wanted to go to Texas with VIS, and he signed the form and left. During an interview on 3/30/22 at 4:55 p.m., with the ADM, the ADM stated she had been present when Resident 1 signed the AMA form and left the facility. The ADM stated she saw VIS and Resident 1 walk to a car, get inside the car, and VIS drove away with Resident 1 in the car. A review of the facility document titled, "Discharge Against Medical Advice Form," indicated, "The resident is advised to contact his/her responsible party, go to an emergency room, or call 911 for further instructions on medical care and treatment," followed by two lines with entries for, "Date: 3/28/22," and "Time: 6:10 p.m." The document indicated, "This is to certify that I am leaving the facility, [facility name], at my own insistence and against the advice of my physicians and the facility. I have been advised of the risk involved and of possible dangers to my life or health from this departure and I hereby assume the risks and consequences involved. I release my physician, [physician name], the facility and all facility staff members from any liability in connection with my leaving the facility against their advice. Payment in full is hereby guaranteed for all services provided by the Facility, up to and including the day of leaving the Facility." The document indicated entries for, "Resident name: Resident 1's name, Signature of Resident: Resident 1's signature, Witness: LVN 1." The document had no entries in the areas which indicated, "If resident is unable to consent by reason of age or some other actor, state reason(s)," and, "If Discharge is requested by the Resident's Legal Representative or Responsible Party:, Name:, Signature:, Relationship to Resident." A review of the facility's policy and procedure, "Discharge against medical advice," dated 12/1/14, indicated "... if the resident /representative's is still determined to leave against medical advice, the licensed nurse will obtain a physician's order for resident to leave AMA." The facility failed to follow the facility policy and procedure when they failed to obtain a physician order for discharging against medical advice. In addition, the policy and procedure did not indicate what the facility actions should be when a resident without capacity and without a legal representative wanted to leave the facility AMA. A review of the facility's policy and procedure, "Discharge Planning," revised November 2020, indicated "The facility ensures the discharge needs of each resident are identified and results in the development of a discharge plan...The IDT will consider the caregiver/support person availability and the resident's or caregiver's/support person's capacity and ability to provide required care, as part of the identification of discharge needs...A post-discharge plan of care is developed with the resident and/or resident representative, which will assist the resident in preparing for discharge to a new living environment; including resident and/or resident representative education, referrals for home health, DME, or other community services arranged to support the safety and care of the resident. Steps taken to prepare the resident for discharge will be documented in the medical record." Resident 1, a resident without capacity for healthcare decisions, signed a discharge against medical advice form and left the facility in the care of a woman of unestablished status and no documented training/education for Resident 1's post-discharge care needs. The facility failed to: 1. Develop and update a comprehensive discharge plan for Resident 1, 2. Provide documented training and education to a responsible party for the post-discharge care of Resident 1, a resident without capacity for healthcare decisions, 3. Develop/implement a policy and procedure for establishment of a patient representative for unrepresented residents, without legal capacity, who wish to refuse further treatment by discharging against medical advice. 4. Follow policy and procedure to obtain a physician order for discharge against medical advice. This had the potential to result in physical, emotional, or psychological abuse/neglect for Resident 1, a resident without legal capacity and without a responsible party.