Health inspection·April 2, 2025

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a post discharge follow-up was conducted and documented in the medical records for one of three residents reviewed (Resident 1). Residents Affected - Few This failure had the potential to compromise Resident 1's safety and well-being by not ensuring post-discharge needs were met. Findings: A review of Resident 1's medical record indicated he was admitted to the facility on [DATE], with diagnoses which included left tibia (leg bone) fracture and type 2 diabetes mellitus (abnormal high sugar). Resident 1 was discharged on January 22, 2025. A review of Resident 1's History and Physical, dated September 5, 2024, indicated he had capacity to understand and make decisions. A review of Resident 1's Order Summary, dated January 21, 2025, indicated, .LCD (last cover day) 1.21.25 (January 21, 2025) D.C. (discharge) 1/22/25 (January 22, 2025) at 11:00am, to address (provided) . A review of Resident 1's NOTICE OF PROPOSED TRANSFER/DISCHARGE, effective date of January 22, 2025, indicated .The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by the facility . A review of Resident 1's Progress Notes, dated January 22, 2025, at 12:33 p.m., indicated .pt (patient) discharged . A further review of Resident 1's progress notes indicated, there was no documentation showing that the Case Manager (CM) followed-up with the resident after his discharge. On March 5, 2025, at 10:25 a.m., a concurrent interview and record review were conducted with the Social Service Director (SSD). The SSD stated when a patient was discharged , she and/or the CM would call the resident at least 72 hours after discharge to check in and provide additional information as needed. The SSD stated, she maintained a binder containing her post-discharge follow up call logs, while the CM kept track of her own logs. The SSD stated, Resident 1's discharge had been coordinated by the CM, and was unsure whether the CM conducted a follow up call for Resident 1. On March 6, 2025, at 12:35 p.m., a concurrent interview and record review were conducted with the Page 1 of 2 056162 056162 04/02/2025 Extended Care Hospital of Riverside 8171 Magnolia Avenue Riverside, CA 92504

F 0660 Level of Harm - Minimal harm or potential for actual harm Director of Nursing (DON). The DON stated, per facility policy, the social services and case management departments were responsible for calling and checking in on residents at least 72 hours after discharge and again between 14-28 days post-discharge. The DON stated, there was no documentation showing that Resident 1 was contacted after discharge. The DON stated, Resident 1 should have received a follow up phone call to ensure Resident 1's post discharge care needs were met and the resident remained safe. Residents Affected - Few A review of the facility's policy and procedure titled, Follow Up Discharge Phone Call, revised December 2024, indicated .the purpose of follow up discharge call is .within 72 hours of discharge, as this is the time when most patients will have questions and need reassurance, advice and reinforcement of information provided upon discharge .to check patient's condition and support discharge instructions . A review of the facility's policy and procedure titled, Documentation in Medical Record, revised on December 2022, indicated .each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress .licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record .documentation shall be accurate, relevant and complete, containing sufficient details about the resident's care . 056162 Page 2 of 2