Other·April 6, 2022

Section 483.15(e) Permitting Residents to return to facility. Section 483.21(e)(1) The 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. 22 CCR Section 72520(a) Bed Hold (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. On 3/16/2022 at 3:39 p.m., an unannounced visit was conducted at the facility to investigate a compliant regarding Admission, Transfer and Discharge Rights. On 3/9/2022, Resident 1 was transferred from the facility to a General Acute Care Hospital (GACH) for an acute change in behavior. The Resident was cleared by the GACH emergency department's physician and psychiatrist to return to the facility on the same day (3/9/2022). The facility failed to readmit patient back to the facility after psychiatric evaluation, which caused undue stress and anguish resulting in Resident 1 remaining in the GACH emergency department for past 27 day awaiting to return to the facility. This failure resulted in refusal readmit Resident 1 back to her home and caused avoidable and undue stress and anguish and had the potential to negatively affect the resident 1's comfort and psychosocial well-being. During a review of Resident 1's document titled "Admission Record", dated, 3/15/22, the Admission Record indicated, Resident 1 was admitted on 11/29/21, with a primary diagnosis of Unspecified Dementia with Behavioral Disturbance (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and essential hypertension (persistent high blood pressure for which no specific cause can be found). The Admission Record indicated that Resident 1 was her own responsible party, and her son was the emergency contact. During a review of Resident 1's Minimum Data Set (MDS- standardized assessment for nursing homes), dated 12/12/21, Section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a series of questions to determine how one is cognitively (understanding of thoughts, experiences, and senses) functioning at that time) score of 9 out of 15, indicated that Resident 1 had moderately impaired cognition (0-7 points: severely impaired cognition; 8-12 points: moderately impaired cognition; 13-15 points: intact cognition). During an interview on 3/16/22, at 1:42 p.m., with the Social Work Manager (SWM) at the GACH, the SWM stated Resident 1 came to the GACH on 3/9/22 on a 5150 hold (section of the Welfare and Institutions Code, which allows a person with mental challenge to be involuntarily detained for a 72-hour psychiatric hold). SWM stated, Resident 1 was cleared by Behavioral Health on 3/9/22 and the hold was removed. SWM stated Resident 1 was never admitted to the GACH, remains in the emergency department and has been ready to return to the facility since 3/9/22 but the facility had been refusing to take Resident 1 back. The SWM stated Resident 1 was stable and appropriate and wants to return to the facility. During a review of Resident 1's Behavioral Health Crisis Eval, dated 3/9/22, at 7:56 p.m., it indicated, "...Removed pt [Resident 1] from 5150 per note pt is A&O x 3 [alert and oriented times person, place, and time] denies SI [suicidal ideations] and denies being a danger to others, was calm, cooperative, and maintained good eye contact. She was able to recall the events from the night before stating "I was yelled at by a couple of staff and I got frightened and I resisted them. I guess I was yelling too. I fought back at them. I did not want to run away. I don't know why they are saying that." She stated she did want to go back to her trailer in the mountains that she was removed from because there was a fire. Clt [client- Resident 1] answered every question coherently and no signs of dementia noted at this time. By ... Referred to [hospital] case management for further discharge planning..." During an interview on 3/16/22, at 3:45 p.m., with the Director of Nursing (DON-Skilled Nursing Facility), the DON stated, "She [Resident 1] was acting 5150 on the 8th [3/8/22], acting mentally deranged, threatening her roommate verbally. She walked out the back door, but staff was able to get her back in. She did fight them kicking, biting, and pinched the breast of one of the CNA (certified nursing assistants). Then they got her back in the room. She wanted the door shut, they shut it and then when they opened it, she had broken the screen out of her window and threw her stuff out of it. The DON stated the staff came in and took her away from the window and we placed her on a 1:1 with a staff member. DON stated my Social Services, Administrator, and my Assistant DON were the ones involved, I was on a conference call and had to be informed of the incident. The DON stated, "This was an emergency situation, so yes we did the discharge appropriately. The Sheriff made the decision [to make Resident 1 a 5150]. We told the hospital the next day when they called us to take her back, we told them we would not accept her back and we assumed they were going to find her another facility. Hopefully a lockdown facility or dementia area. No, we didn't send any paperwork with her because it was an emergent situation and the sheriff placed her on a 5150, we thought that was enough." During an interview and record review, on 3/16/22, at 5:40 p.m., with the Admissions Director (AD-Skilled Nursing Facility), Resident 1's Admission Agreement, dated 11/29/21 was reviewed. The AD confirmed that Resident 1's Admission Agreement was signed by her son. The AD stated when Resident 1 was admitted she came by ambulance and did not want to be here, so she refused to sign the admission agreement, so her son did. The AD stated she had tabs placed on the agreement where she stated the facility has the right to refuse to take Resident 1 back. Resident 1's Admission Agreement indicated, "...VI. Transfers and Discharges You can leave our Facility at any time without prior notice to us. We will help arrange for your voluntary discharge or transfer to another facility. Except in an emergency, we will not transfer you ... to another facility and will not discharge you from our Facility against your wishes, unless we give prior written notice to you. The only reasons that we can transfer or discharge you against your wishes are: 1) It is required to protect your well-being, because your needs cannot be met in our Facility; ... 3) Your presence in our Facility endangers the health and safety of other individuals... Our written notice of transfer or discharge against your wishes will be provided 30 days in advance. However, we may provide less than 30 days notice if the reason for the transfer or discharge is to protect your health and safety or the health and safety of other individuals... Our written notice will include the effective date, the location to which you will be transferred or discharged, and the reason the action is necessary. In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Services, Licensing and Certification Division, and we will also provide the name, address, and telephone number of the State Long-Term Care Ombudsman. If you are transferred or discharged against your wishes, we will provide transfer and discharge planning as required by law..." During a review of Resident 1's "Administrator Note," dated 3/9/22, at 6:08 p.m., the Administrator Note indicated, "...Incident report for day after [Resident 1's name] tried to leave AMA [against medical advice] on March 8th on March 9th at 9:30 AM until 3:30 PM [Name] SSD (Social Services Director) and I dealt with [Resident 1]. We wanted to make sure that her needs were being met and that she didn't leave the facility against medical advice. The day before she wanted to leave the facility and we convinced her to stay until we could get her the resources that she needed to be OK in the community. On March 9th at 10:13 AM we spent an hour on the phone with the ombudsman [name]. [Name] SSD and I tried to convince [Resident] to stay until we got her the proper resources to be able to go back home. We realized that home was about five hours north near [name of city] and she didn't have an exact address so while I was willing to pay for the Uber for her to get there safely, she did not know the address of where she was trying to build the home on the property. We called her son and spent about 30 minutes on the phone finding out her tree [this is verbatim] and he also did not know the address, nor did he have her ID or any documentation because she refused to give it to him and unfortunately, she lost it since refusing to give it to him. This caused a problem in sending her to an unknown address and having her check into a hotel realizing that she did not have any documentation to prove who she was. During the time that [Resident 1] was in my office with [SSD] and we were convincing her to use one of our laptops for as long as she wanted so that she could figure out where she would go next, she saw our housekeeping director and said she loved him. [name] the ombudsman brought to her attention, but she seems to be surrounded by people who love her and want the best for her yet she's trying to leave [Resident 1] did not have any rebuttal for this statement and she knew it was true. She said I need to leave and kept saying that. We then called for our medical director doctor [name] and asked him what he would suggest. Doctor [name] said if she's her own responsible party there's nothing, we can do from her deciding to leave against medical advice. He suggested to take good notes on the situation and send it over to him to have him sign that he had spoken and that we were doing the right thing by the resident. [Name of ombudsman], [name of SSD] and I tried for hours to convince her to stay until we had the right resources for her to be successful when she left. She didn't seem very calm about the whole situation she was noticeably anxious and on high alert. Since the previous night on March 8th when she tried to leave, we had a one-on-one sitter with her for her safety, her roommate safety and my staff safety and decided our best bet at this point would be to call the Sheriff's Office in and let them decide if she needs to be taken to an acute hospital on a 5150. At about 1:30ish They ultimately decided that it was her best interest to leave on a 5150 and proceeded to do so [Resident 1] got what she wanted and was taken to [name of hospital]. [DON's name] said it perfectly [Resident 1] behavior was just enough to be not be reportable I mean it was just it was it wasn't over the top to be reportable. She would constantly whisper to her roommate things that made her uncomfortable but not enough to be reportable but yet enough to make a roommate uncomfortable and fearful..." This note was signed by the Medical Director, DON, AD, SSD, ADON and other staff on 3/15/22. During a concurrent interview and record review on 3/16/22, at 5:15 p.m., with the DON, Resident 1's Doctors Progress Note, dated 3/6/22 was reviewed. The DON stated this was the last time the doctor had seen the resident in the facility. Resident 1's Doctors Progress note indicated, "... Notes reviewed? Yes Weight Gained Vital Signs Stable Afebrile [no fever] CV [cardiovascular]: regular Lung: CTA [clear to auscultate] Abdomen: Benign [no issues] ... Neuro Alert... HTN [hypertension- high blood pressure] Anxiety Depression... up active..." The DON stated the Administrators note dated 3/9/22 was the only note signed by the Medical Director in regard to Resident 1's behaviors and transferred to the hospital. The DON stated there is no other documentation by the Medical Director for Resident 1 after 3/9/22. The DON stated Resident 1 did not have a Psychiatric Evaluation done but they do have a mental health provider that does see residents in this facility. During a concurrent observation and interview on 3/28/22 at 11:52 a.m., with Resident 1, in the GACH emergency department (ED) in a private room, Resident 1 was sitting up in a hospital bed, eating lunch. Resident 1 appeared clean and well-groomed. Resident 1 stated, "Yes," when asked if she wanted to return to the nursing facility, she stated "Yes" that she had friends at the facility but also stated, "and some enemies too. But I took care of my enemies." She was encouraged to explain what she meant by that but just started to laugh. When asked if she felt she was getting the care she needed in the ED she stated, "I think so." Then asked if staff in the ED were friendly, she stated, "some are nice and some are nasty," she then stated that lunch "tasted terrible." Resident 1 was observed eating meat, potatoes, zucchini, and apple crisp. Resident 1 stated her son lived in the area but had not come to visit, he had visited her once at the nursing facility, but he was "too busy." Resident 1 stated she would go home with her son, then said she would not want to live with him. In between Resident 1's coherent responses she inserted comments that were not connected to the conversation. During an interview on 3/30/22, at 12:52 p.m., with Resident 1's Son, the son stated, "I called over to the facility and was placed on speaker phone on Wednesday [3/9/22] and I talked with them [the staff] and then I talked with my mom, and everything was fine. They were trying to tell me that she had an episode where she wanted to leave, and it took five of them to get her back into her room. When I talked with my mom she had calmed down and was okay with staying until Saturday because that is when I was going to head up there to see her. The next day they called me and told me that they had called the Sheriff and had her removed for threatening others and trying to leave. If I knew they were going to remove her forcefully like that I would have taken the time off and come up sooner. Friday, they called me and asked me what they should do with her belongings, and I ended up driving up on Saturday and picking them up. No, they never mentioned a seven-day bed hold... nor did they mention any appeal process for discharge." The son then stated "No" I don't think my mom is cognitive enough to make medical decisions for herself and "Yes" I would consider myself her representative." During the review of the Resident 1's Admission Agreement, dated 11/29/21, it indicated, "... II. Identification of Parties to this Agreement Definitions... the parties to this agreement are the Resident, the Facility, and the Resident's Representative. References to the "Resident's Representative" are references to: [Resident 1's sons name], the person who will sign on your behalf to admit you to this Facility, and/or who is authorized to make decisions for you in the event that you are unable to. To the extent permitted by law, you may designate a person as your Representative at any time... VII. Bed Holds and Readmission If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You and your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you... If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulation Sections 72520 (c) and 73504 (c)) to offer you the next available appropriate bed in our Facility. You should also note that, if our Facility participates in Medi-Cal and you are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted..." During a review of the facility's policy and procedure titled, "Readmission to the Facility", dated 2021, in