Health inspection·October 10, 2024

Golden Sonora Care Center The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # CA00904183 Survey Event ID: 771Z11 State Citation B was written. Code of Federal Regulations, Title 42, Section §483.15(e)(1) (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. California Code of Regulations, Title 22, Section §72527(a)(6) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. California Health and Safety Code, Section §1599.1 h(1)(2)(3) (h)(1) If a resident of a long-term health care facility has been hospitalized in an acute care hospital and asserts his or her rights to readmission pursuant to bed hold provisions, or readmission rights of either state or federal law, and the facility refuses to readmit him or her, the resident may appeal the facility's refusal. (2) The refusal of the facility as described in this subdivision shall be treated as if it were an involuntary transfer under federal law, and the rights and procedures that apply to appeals of transfers and discharges of nursing facility residents shall apply to the resident's appeal under this subdivision. (3) If the resident appeals pursuant to this subdivision, and the resident is eligible under the Medi-Cal program, the resident shall remain in the hospital and the hospital may be reimbursed at the administrative day rate, pending the final determination of the hearing officer, unless the resident agrees to placement in another facility. On 6/11/24 at 9:15 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding discharge. The Department determined the facility failed to ensure Patient 1's right to return to the facility was protected when: 1) Patient 1 was sent to the hospital and was not allowed to return to the facility on 6/7/24, 2) A facility physician did not document a basis for Patient 1's discharge; and 3) The facility failed to provide a written Notice of Transfer or Discharge to Patient 1, Patient 1's representative (RP), and the Long-term Care (LTC) Ombudsman (a patient rights advocate). These failures placed Patient 1 at risk for emotional distress, removed the opportunity for the State LTC Ombudsman to advocate on Patient 1's behalf, and deprived Patient 1 or his RP of information regarding rights to appeal the transfer/discharge. 1. Review of Patient 1's Admission Record indicated Patient 1 was admitted to the facility in 2024 with diagnoses including prostate cancer and secondary malignant neoplasm of brain (cancer cells spreading to the brain from another part of the body). Review of Patient 1's hospital record, "Behavioral Health Consultation," dated 6/7/24, at 2:53 p.m., indicated, "...He has been calm and cooperative in the ED for approximately 8.5 hours. The patient does not have a mental health diagnosis which would be responsible for his symptoms...would not benefit from inpatient psychiatric hospitalization. Patient's behavior likely in the context of medication non-compliance and medical co-morbidities. Discussed r/b/a [risks, benefits and alternatives] of treatment options with the patient and his brother who were agreeable to receiving [name of psychotropic medication] and returning to the SNF [skilled nursing facility]..." Review of Patient 1's electronic health record (EHR) titled, "Progress Notes," dated 6/7/24, at 6:40 p.m., indicated, "...RP...contacted via phone by this nurse r/t [related to] [Patient 1] being sent back to [Hospital]...This nurse informed [RP] that [Patient 1] had been sent back to acute care r/t aggressive behaviors..." Review of Patient 1's hospital record, "Emergency Department Reports," dated 6/7/24, at 6:49 p.m., the "History" section indicated, "...BIBA [brought in by ambulance] from [name of facility] per...staff request. Pt [patient] was in ED [emergency department] earlier today for agitation...later released by behavioral health. Pt currently on hospice [care provided at end of life] for metastatic CA [cancer which has spread] with mets [metastases-sites of spread to other areas of the body] to the brain...his hospice team was contacted earlier today from ED regarding medication management and medication changes to keep him more comfortable and to decrease his agitation and pt was discharged back to [facility name] this afternoon. On my evaluation patient has no complaints..." Review of Patient 1's hospital record, "Emergency Department Reports," dated 6/7/24, at 6:49 p.m., the "Medical Decision Making" section indicated, "...Patient is currently calm and cooperative...I discussed with [facility physician name] that if they feel he requires more care than they can provide this is something that they need to arrange for a transfer from [facility name]. There is no indication for patient to be admitted or transferred from the ER [emergency room] today, given patient is confirmed on hospice and with extensive discussion earlier today with case management and administration decision was made for patient to ultimately be discharged back to [facility name] with continued hospice care..." Review of Patient 1's hospital record, "Emergency Department Reports," dated 6/8/24, at 1:26 a.m., the "Chief Complaint" section indicated, "Pt BIBA from [facility name]. Was originally sent back there and the staff refused to accept their patient back. He was abandoned and medics had to bring him back here." Review of Patient 1's hospital record, "Emergency Department Reports," dated 6/8/24, at 1:26 a.m., the "Medical Decision Making" section indicated, "...Unfortunate case of patient returning to the ER as [facility name] refused to accept patient back after he was discharged a few hours ago from the ER back to his care facility...Has been calm and cooperative while in the ER ..." During an interview on 6/26/24, at 8:28 a.m., licensed nurse (LN) 1 stated on 6/7/24, at 11 p.m., Patient 1 returned from the hospital in an ambulance with paramedics accompanying him. LN 1 stated Patient 1 was brought up to the door on a stretcher and was denied entrance to the facility. LN 1 further stated, "...We refused to take him back..." During an interview on 7/16/24, at 1:48 p.m., with the hospital Case Manager (CS), the CS stated the facility would not accept Patient 1 back. The CS further stated she did not receive any notice that Patient 1 was discharged from the facility because he was dangerous. During an interview on 7/19/24, at 2:15 p.m., with the Hospice Doctor (HD), the HD stated, "...The facility should have taken him back ...That's the place he lives. He should be allowed back. They should have reached out to our team if the facility felt the resident was a danger. We have social workers that work with other facilities to find placement...The hospital can't keep him because of his hospice (a program that provides specialized care to people who are near the end of life and have stopped treatment to cure or control their disease) diagnosis. The facility doesn't want him back, a man without a place to stay...We tried to adjust meds, but couldn't move too fast and have to go slow with them ..." The HD indicated a conversation should have taken place to assess Resident 1's care needs. 2. During an interview on 7/16/24, at 1:35 p.m., with the Medical Director (MD), the MD stated Patient 1 was on hospice and was not his patient. The MD confirmed he did not document the reason for Patient 1's discharge from the facility or if he considered Patient 1 unsafe to remain at the facility. The MD stated no one from the facility asked him to document the basis for Patient 1's discharge. The MD further stated the discharge documentation should have been handled by hospice and completed by the hospice physician. During a concurrent interview and record review on 7/16/24, at 2:08 p.m., with the Social Services Director (SSD), Patient 1's EHR was reviewed. The SSD confirmed there was no physician documentation which justified Resident 1's discharge. During an interview on 7/16/24, at 3:05 p.m., with the Administrator (ADM), the ADM acknowledged there was no physician note found in Patient 1's chart that documented why Patient 1 was discharged from the facility or why he was considered unsafe to remain in the facility. During an interview on 7/19/24, at 2:15 p.m., with the Hospice Doctor (HD), the HD stated Patient 1 was his hospice patient. The HD confirmed he did not document Patient 1's discharge and was not asked by the facility to justify the discharge. The HD stated a conversation should have happened between the facility and his team to determine if it was not appropriate for Patient 1 to stay in the facility. Review of the facility policy titled, "Transfer or Discharge Notice," revised March 2021, indicated, "...The reasons for the transfer or discharge are documented in the resident's medical record..." 3. During a concurrent interview and record review on 7/16/24, at 2:08 p.m., with the SSD, Patient 1's EHR was reviewed. The SSD confirmed no discharge notice was given to Patient 1 or his RP. The SSD stated a discharge notice was given in advance for a facility-initiated discharge or it was given as soon it was known. The SSD further stated she expected a discharge notice be given to a resident and the RP if a resident was considered unsafe to remain at a facility. The SSD explained the purpose of the discharge notice was to let the resident and the RP know and prepare them for the discharge. The SSD stated it was the responsibility of the social services department and the MDS (minimum data set- an assessment tool) nurse to provide the discharge notices. The SSD further stated not providing a discharge notice could affect a resident's family's ability to coordinate care at home. The SSD stated she did not know if a discharge notice should have been given to Patient 1 when facility staff refused to admit the resident back from the hospital on the evening of 6/7/24. During an interview on 7/16/24, at 3:05 p.m., with the ADM, the ADM acknowledged a written discharge notice was not provided to Patient 1 or his RP. The ADM stated she verbally told the RP, but the RP was on a cruise. The ADM further acknowledged a discharge notice could have been given to the next emergency contact for Patient 1. The ADM stated she did not document her conversation with the resident's RP in Resident 1's EHR. During an interview on 7/19/24, at 2:40 p.m., with the ADM, the ADM confirmed a written notice was not provided to the LTC Ombudsman when Patient 1 was no longer at the facility and was discharged. The ADM stated she called Ombudsman to notify them Patient 1 was being sent to the hospital and would not be returning because Patient 1 was considered unsafe to remain at the facility due to his aggressive/ combative behaviors. The ADM further stated she did not document her conversation with the Ombudsman in Patient 1's chart but she should have. The ADM stated she considered it as a discharge when a resident went home, went to a lower level of care or when a resident was no longer in the facility's care. Review of the facility policy titled, "Transfer or Discharge Notice," revised March 2021, indicated, "...Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge...The safety of individuals in the facility would be endangered...The health of individuals in the facility would be endangered...The resident and representative are notified in writing of the following information...The specific reason of the discharge...A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative..." Therefore, the Department determined the facility failed to ensure Patient 1's right to return to the facility was protected when: 1) Patient 1 was sent to the hospital and was not allowed to return to the facility on 6/7/24, 2) A facility physician did not document a basis for Patient 1's discharge; and 3) The facility failed to provide a written Notice of Transfer or Discharge to Patient 1, Patient 1's representative (RP), and the Long-term Care (LTC) Ombudsman (a patient rights advocate). Patient 1 was at risk for emotional distress, removed the opportunity for the State LTC Ombudsman to advocate on Patient 1's behalf, and deprived Patient 1 or his RP of information regarding rights to appeal the transfer/discharge. As a result, Patient 1 underwent an unnecessary prolonged hospitalization while placement was found and eventually Patient 1 was sent to an unfamiliar facility. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1.