Health inspection·June 7, 2022

The following reflects the findings of the California Department of Public Health during the investigation of Complaint CA00782555 Event ID: Representing the Department: HFEN, 2892 State Citation B was written. F626, 483.15(e)(1)(2) Permitting Residents to Return to Facility §483.15(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. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. On 4/29/22 at 12:00 p.m. an unannounced visit was conducted at the facility to investigate a complaint regarding Admission, Transfer and Discharge Rights. The facility failed to permit Patient 1 back to the facility after a psychiatric evaluation and an involuntary psychiatric hold (5150) had been removed. This deficient practice had the potential to compromise the patient's psychosocial well-being. Review of the Patient 1's clinical record indicated he was admitted to the facility on 6/1/2020 with diagnoses including cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), memory deficit (reduced ability to remember things such as dates and names, and increased forgetfulness), and anxiety disorder (a mental health disorder characterized by feelings of worry or fear). Review of the Patient 1's minimum data set (MDS, an assessment tool) dated 1/12/22, indicated Resident 1 had severely impaired cognitive skills for daily decision making. Review of the Patient 1's nurses notes dated 3/23/22, indicated he was sent out to a general acute-care hospital (GACH) on a 5150 hold. Nurses' notes further indicated a non-emergency number was called after the patient was found crawling on the floor, attempting to hit and bite staff. It further indicated an order for a 5150 hold was obtained by the physician and the patient was picked up by emergency medical technicians (EMT) and taken to a GACH. Review of the Patient 1's physician's orders dated 3/23/22, indicated bed-hold for seven days. Review of the GACH emergency psychiatric services (EPS) medical screening evaluation dated 3/24/22, indicated Patient 1 was admitted to EPS for observation, evaluation, and treatment. It further indicated Patient 1 did not have a prior psychiatric history and he had been calm and cooperative without exhibiting any behaviors while in EPS, and he adamantly denied any desire to hurt himself or others. It further indicated Patient 1 was not holdable and the 5150 hold was removed. It further indicated the facility refused to take Patient 1 back. A review of a "Decision and Order Appeal," dated 4/19/22 indicated on March 17, 2022, the facility issued a Notice of Proposed Transfer/Discharge (Notice) to Patient 1's Representative for the effective discharge of Patient 1 on April 22, 2022. On March 23, 2022, Patient 1 was transferred to an acute-care hospital for evaluation and treatment under an involuntary psychiatric hold. On March 23, 2022, Patient 1's representative asserted Patient 1's right to readmission and filed an appeal of Patient 1's proposed discharge. On or about March 25, 2022, the facility failed to readmit Patient 1. The hearing in the matter took place on April 11, 2022. The appeal indicated when the facility refused to readmit Patient 1 on or about March 25, 2022, they had previously begun the process of involuntary discharging Patient 1 by issuing a Notice to Patient 1's representative on March 17, 2022. In a final decision the facility must immediately readmit Patient 1 to the facility. The facility complied with the Decision and Order and re-admitted Patient 1 back on 4/23/22. During a telephone interview with the director of nurses (DON) on 4/29/22 at 12:50 p.m., the DON stated she spoke with the GACH case manager (CM) and told her she did not want to take Patient 1 back. The DON also stated she told the CM she could not take Patient 1 back if his behaviors were not managed. During a subsequent telephone interview with the DON on 5/10/22 at 11:56 a.m., the DON stated we did not take Patient 1 back because we could not meet his needs. During a subsequent telephone interview with the DON on 6/1/11 at 2:28 p.m., the DON stated Patient 1 was on a bed-hold and hospital leave and the room was available. The DON further stated we waited two weeks for the hearing and then another one week for the decision. The DON also stated once denied we took Patient 1 right back. In violation of the above cited standards, the facility failed to permit Patient 1 back to the facility after a psychiatric evaluation and a 5150 hold had been removed resulting in Patient 1 remaining in the GACH from 3/24/22 through 4/21/22 pending placement to another facility. This violation had a direct or immediate relationship to the health, safety, comfort and well-being of patient.