Health inspection·April 11, 2025

Noble Care Center The following reflects the findings of the California Department of Public Health during the investigation of one complaint #CA00950112. Event ID: 42UJ11 Exit: 3/19/25 State Citation B was written for F660 California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Code of Federal Regulations, Title 42, §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and- (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. On 3/19/25, at 9 am, an unannounced visit was conducted at the facility to investigate one complaint (CA00950112) regarding a resident discharge. The department determined the facility failed to ensure Resident 1 had a safe discharge plan in place when Resident 1 expressed wanting to leave the facility against medical advice (AMA - a situation where a resident left a facility without following the physician's recommendation for treatment). This failure resulted in Resident 1 leaving the facility AMA when he was not equipped to meet his healthcare needs and was found lying in an unknown person's front yard 3.4 miles from the facility, confused and gravely disabled (a person who was unable to provide for their basic needs [food, clothing, shelter, gravely disabled personal safety, or necessary medical care]). Resident 1 had a ground level fall with positive head strike on 2/8/25 and was brought to an ACUTE CARE HOSPTIAL for acute encephalopathy, with imaging of the head indicated a brain bleed. He was transferred to the facility on 2/13/25 with orders to have Physical Therapy and Occupational Therapy, and nutritional consult. Resident 1 had a history of atrial fibrillation (irregular heartbeat), heart failure, Amphetamine use disorder, and kidney disease. Upon admission to the facility, Resident 1 demonstrated cognitive impairment (confusion) and was oriented to person but not to place, time, or event. He was on fall precautions. At approximately 10:00 a.m. on 2/16/25, Resident 1 left the facility AMA and was later found lying on a homeowner's front yard (approximately 3.4 miles from the facility) by the police, at approximately 4:47 p.m. Resident 1 was sent to an Acute Care Hospital for altered mental status on 2/16/25 and discharged home on 2/21/25. During a concurrent interview and record review on 3/19/25 at 11:22 a.m., with Licensed Nurse (LN) 1, Resident 1's document titled, "Progress Notes", dated 2/16/25, was reviewed. The record indicated, "Resident [Resident 1] was ... restless, wandering around the facility claiming he 'needed to leave'. During AM [morning] medication pass, resident began to pack his belongings and when asked where he was going, he would state 'to go with my wife' (wife not on scene) ...Resident ...does have intermittent episodes of forgetfulness and is a poor historian ...resident left the facility with his bag (no medications discharged with patient) ..." LN 1 stated Resident 1 verbalized that he wanted to leave the facility for approximately two hours before he left AMA. LN 1 stated she texted MD 1 that Resident 1 wanted to leave the facility, but she never received a text back. LN 1 stated there was not a follow up phone call to the MD (Medical Doctor) until after Resident 1 left the facility. LN 1 stated Resident 1 did not have a walker (used to provide support and stability while walking) when he left the facility. LN 1 stated she did not notify the ombudsman (an independent official that attempted to resolve conflicts or concerns raised by a resident), the facility social services director (SSD), or Adult Protective Services (APS - an outside agency that helps adults who are unable to meet their own needs, or are victims of abuse, neglect or exploitation) that Resident 1 wanted to leave the facility AMA. LN 1 acknowledged she did not document in Resident 1's clinical record specific alternatives to AMA that were offered to Resident 1. LN 1 stated it was her first time she had a resident leave AMA, and she was unsure whom she was supposed to notify. LN 1 stated Social Services would have been a great support to Resident 1 and could have possibly provided Resident 1 safe transportation from the facility to his home. LN 1 stated the Ombudsman could have provided Resident 1 with some community resources. LN 1 stated she was unaware if she should have called APS. A review of the document titled, "Incident Report [CITY NAME 2] Police Department", dated 2/23/25, at 9:53 a.m., by Deputy Officer (DO) 1, indicated “at approximately 10:00 a.m. on 2/16/25, Resident 1 left the facility AMA and was last seen walking on foot in an unknown direction away from the facility. At 12:32 p.m., DO 1 was alerted that Resident 1's family member (FM) had filed a missing person's report. DO 1 called FM and FM stated he had gone to the facility to visit Resident 1, and the facility staff had advised him that Resident 1 had left the facility earlier that morning. Upon hearing this, FM drove around [CITY NAME 2] and looked for Resident 1 because FM was not sure if Resident 1 could get home independently. On 2/16/25, at approximately 4:47 p.m., DO 2 and DO 3 were sent on a call that a man (Resident 1) was laying on a homeowner's front yard (approximately 3.4 miles from the facility). Resident 1 stated he was lying on the yard because he had fallen. Upon arrival, DO 2 and DO 3 determined Resident 1 was unable to properly care for himself and considered Resident 1 gravely disabled. Resident 1 lived in [CITY NAME 1] approximately 21 miles from the facility. APS was notified, and Resident 1 was placed on a 72-hour evaluation hold (temporary involuntary detention for evaluation and treatment when a person was deemed a danger to themselves, others, or are gravely disabled) and sent to [ACUTE CARE HOSPITAL NAME].” A review of Resident 1's clinical record (from the Hospital Emergency Department), titled, "[ACUTE CARE HOSPITAL NAME] Discharge Summary," dated 2/21/25, indicated Resident 1 remained disoriented while at the hospital and was later discharged home with a bedside commode (portable toilet), front wheeled walker, and a shower chair. A review of Resident 1's clinical record titled, "Fall Risk Assessment", dated 2/13/25, at 2:25 p.m., indicated Resident 1 was a high fall risk related to 1 to 2 falls in the past three months, required use of an assistive device (i.e. cane, w/c walker, furniture), took three or more medications that could have contributed to falls, had a recent change in medication in the past five days, and had 1 to 2 predisposing diseases that could have contributed to falls. A review of Resident 1's clinical record titled, "Care Plan Report" (a document that contained Resident 1's problems, goals and interventions), dated 2/14/25, indicated Resident 1 had declined in functional mobility, had decreased leg strength and coordination, and had increased falls. Resident 1 required moderate to maximum assist with Activities of Daily Living (ADL - brushed hair, brushed teeth, toileted) and moderate assist with mobility skills and safety activity tolerance. A review of Resident 1's clinical record titled, "Section GG - Function Abilities" (a portion of a comprehensive assessment conducted at Skilled Nursing Facilities), dated 2/16/25, indicated Resident 1 required partial to moderate assistance (helper did less than half the effort) with toileting hygiene, upper body dressing, chair to bed transfer, toilet transfers, rolling to the left and to the right while in bed, and assistance when Resident 1 walked 10 feet in a room or 50 feet with two turns in a room. Resident 1 required substantial to maximum assistance (helper did more than half the effort) with lower body dressing and when he put on and took off socks. A review of Resident 1's clinical record titled, "Evaluation Summary," dated 2/14/25, at 12:01 p.m., by the Social Services Director (SSD), indicated prior to admission, Resident 1 lived on the second floor of an apartment building and required home health and durable medical equipment (DME - medically necessary devices and supplies) prior to discharge from the facility. During a phone interview on 3/18/24 at 11:19 a.m., with the Ombudsman (OMB), the OMB stated the facility had not contacted him when Resident 1 had expressed the desire to leave the facility AMA. The OMB stated if he would have been notified, he would have provided AMA instructions to the facility. During a phone interview on 3/18/25, at 2:34 p.m., with APS 1 (an employee of an outside agency), APS 1 stated when Resident 1 left the facility AMA, it was considered self-neglect (not caring for oneself) and was an unsafe discharge. APS 1 stated it was her expectation to be notified when Resident 1 left the facility AMA. APS 1 stated the failure of the facility of not notifying APS when Resident 1 left the facility AMA delayed the process of locating Resident 1 and delayed arranging services to assist Resident 1 with ADL assistance and medical care. During a concurrent interview and record review on 3/19/25, at 10:50 a.m., with LN 2, Resident 1's Electronic Health Record (EHR) at the facility was reviewed. LN 2 stated Resident 1 was a high fall risk. LN 2 stated there were not any progress notes in the record that indicated that staff attempted to provide other options to Resident 1 prior to leaving AMA. LN 2 stated there was no documentation as to the time Resident 1 left AMA or the destination address. LN 2 stated the Ombudsman and APS should have been notified when Resident 1 left AMA but was unsure as to what the OMB and APS would have done to help. During a concurrent interview and record review on 3/19/25, at 12:10 p.m., with LN 3, LN 3 stated the LN on duty should have notified the MD at the first sign that Resident 1 wanted to leave AMA and documented the notification in the EHR. LN 3 stated if the LN was unable to reach the MD, the LN should have attempted to notify the Nurse Practitioner (NP). LN 3 acknowledged the times the LN attempted to reach the MD were not documented in Resident 1's clinical record. LN 3 stated Resident 1 was not safe to leave the facility AMA because he was a high fall risk. LN 3 stated the ombudsman, and APS should have been notified when Resident 1 left AMA because Resident 1 was at risk for injuries. During an interview on 3/19/25, at 12:25 p.m., with the SSD, the SSD stated she would have liked to have been notified when Resident 1 expressed he wanted to leave the facility AMA. The SSD stated she would have attempted to create a safer plan (such as home health-medical care provided in a person's home) upon leaving AMA. The SSD stated she would have asked Resident 1 to wait until the MD could assess Resident 1's ability to safely leave the facility. The SSD stated Resident 1 had lived in an apartment approximately 21 miles from the facility and the staff had not formulated a plan on how Resident 1 was going to get home. The SSD stated she would have expected the LN to document all attempts that were made to have Resident 1 agree to remain at the facility until a safe discharge plan could have been arranged. During a phone interview on 3/19/25, at 2:10 p.m., with the MD, the MD stated when he assessed Resident 1 upon admission Resident 1 had intermittent confusion. The MD stated he was not aware Resident 1 had left AMA until after Resident 1 had already left the facility. The MD stated if he would have been made aware of Resident 1's desire to leave AMA, he would have attempted to have a conversation with Resident 1 to ascertain (conclude) why Resident 1 was eager to leave. The MD stated he would have tried to convince Resident 1 to stay at the facility until he was deemed safe to discharge home. The MD stated the facility could have provided transportation to his home and/or followed up with Resident 1 to ensure he had arrived safely at home. During a joint concurrent phone interview and record reviews on 3/20/25, at 3:35 p.m. with the Director of Nursing (DON) and the Administrator (ADM), the facility's Policy and Procedure (P&P) titled, "Transfer and Discharge (including AMA [Against Medical Advice]), dated 2025, and "Discharge Planning Process", dated 2025, was reviewed. The P&P titled, "Transfer and Discharge (including AMA [Against Medical Advice])", indicated, " ...Discharge Against Medical Advice (AMA) ...the physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of this notification should be entered in the nurses' notes ...The social service designee should document any discussions held with the resident/family in the social service progress notes ...Notify Adult Protection Services other entity as appropriate, if self-neglect is suspected. Document accordingly ...". The P&P titled, "Disch