Other·June 30, 2021

§483.15(c)(1)(i)(ii)(2)(i)-(iii) TRANSFER AND DISCHARGE REQUIREMENTS 483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. On 06/07/21, an unannounced visit was conducted at the facility for the recertification survey. The facility failed to ensure a safe discharge for one of three randomly selected discharged sample residents (Resident 14) when: 1. The facility did not initiate a discharge care plan for Resident 14; 2. The interdisciplinary team (IDT, leaders from different departments discuss the resident's care) did not assess the safety of Resident 14's discharge; Facility discharged Resident 14 to the street and left the resident alone in the street; Facility did not know Resident 14's whereabouts after the discharge; 3. IDT team members were not involved in the resident's discharge; 4. The facility did not provide Resident 14 instruction and education for after-discharge care; 5. The facility did not involve the responsible party (RP, a person who is designated to make the care decisions for the resident) regarding the discharge; facility did not inform RP that Resident 14 was discharged to the street; 6. The facility did not follow the doctor orders regarding Resident 14's discharge; 7. Ombudsman (advocate and liaison between residents and the facility) was not aware that the facility discharged Resident 14 to the street. 8. The facility unsafely discharged Resident 14 to the street on 6/7/21. Resident 14 was admitted to the acute hospital due to weakness and abdominal discomfort (medical condition of unpleasant or painful feeling at the belly area) on 6/8/21. These failures resulted in the facility unsafely discharging Resident 14 with a walker to a local street corner, at two streets, on 6/7/21. The facility did not verify where the resident was discharged and left the resident alone on the street. One day after the facility discharged Resident 14 to the street, on 6/8/21 Resident 14 was admitted to the acute hospital for the further evaluation due to the weakness and abdominal discomfort on 6/8/21. Review of Resident 14's face sheet (document that summarizes a resident's information) indicated Resident 14 was a 62-year old man who was admitted to the facility on 3/5/21. Review of Resident 14's face sheet and the SNF (skilled nursing facility) admission note dated 3/7/21, indicated Resident 14 was admitted from a local hospital after an auto versus pedestrian accident on 2/4/21, in which he was the pedestrian and suffered injuries. Injuries from the accident included the following: a concussion (brain injury), a C4-C5 (Cervical; bones in neck) ligament sprain in the spine (injury to the soft tissue in the neck), T6-8 (Thoracic; bones in upper spine in middle of back) ligament injury, T6 fracture (broken bone in spine), and Lumbar L3 fracture (Lumbar; bones in lower spine in middle of back; broken bone in spine). These injuries resulted in Resident 14 having spinal surgery on 2/16/2021. As a result of the accident, Resident 14 had a right lateral (side) knee degloving (when top layers of skin and tissue are ripped from muscle and bone) with a right knee PCL (ligament in knee) injury (stretched or torn tissue that connect bones together). Resident 14 sustained a right femur fracture (broken thigh bone) , a right clavicle fracture (collarbone), left third and fourth rib fractures, right first through fifth rib fractures, an manubrial fracture (broken sternal bone in middle of chest), and a scalp laceration (wound). Resident 14 also developed a methicillin-resistant staphylococcus aureus (MRSA) (a super bug infection, resistant to some antibiotics) which required ongoing antibiotic treatment (medication to get rid of the infection). Resident 14's history included schizophrenia (mental health disease when people see and/or hear things that are not there, have beliefs not based in reality, and/or disorganized thoughts), bipolar disorder (mood swings from depressive lows to manic highs), alcohol abuse, hypertension (high blood pressure), muscle weakness (generalized), and type 2 diabetes mellitus (medical condition that can result in too much sugar in the blood). During an interview with licensed vocational nurse K (LVN K) on 6/11/21 at 12:56 p.m., LVN K stated Resident 14 had behavioral issues every day with "nonstop" yelling. LVN K stated Resident 14's behavior was the same up until discharge and stated Resident 14 was a "more" difficult resident. Review of Resident 14's physician order dated 3/15/21, indicated to monitor every shift for episodes of schizophrenia manifested by angry outbursts (striking out, yelling, demanding attention). Review of Resident 14's Behavior Monitoring Administration History (BMAH) from March 2021 to 6/7/21, indicated Resident 14 had 39 documented episodes of this behavior in March 2021; 214 documented episodes of this behavior in April 2021; 100 documented episodes of this behavior in May 2021 and 20 documented episodes of this behavior from 6/1/21 to 6/7/21. Review of Resident 14's face sheet indicated Resident 14's responsible party (RP) was a family member. Review of Resident 14's Minimum Data Set (MDS, an assessment tool) dated 3/8/21 indicated Resident 14 had a BIMS (Brief Interview for Mental Status) score of 11 (BIMs score of 8-12 indicates moderate cognitive impairment). During an interview and concurrent record review of Resident 14's care plan with the director of nursing (DON) on 6/17/21 at 8:20 a.m., the DON acknowledged the facility did not initiate a discharge care plan for Resident 14. The DON reviewed Resident 14's medical records and confirmed there was no document to indicate the facility discussed the safety of the discharge for Resident 14. Review of the facility's Policy and Procedure "Discharge Summary and Plan," revised in November 2017, indicated " ...Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan ...The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family post-discharge plan will be developed to assist the resident to adjust to his/her new living environment." During an interview and concurrent record review with the Social Services Director (SSD) on 6/11/21 at 4:22 p.m., the SSD stated an IDT discharge meeting to discuss Resident 14's discharge and the safety of the discharge did not occur. The SSD stated the facility did not have an IDT discharge meeting for Resident 14 because "..we (the facility) were distracted because you (California Department of Public Health survey team entered the facility on 6/7/21 for the recertification survey) all were here." The SSD stated Resident 14 "bugged" her on 6/7/21 from 8:30 a.m. and on. SSD stated "...he (Resident 14) was bugging me and he wanted to go to the street and instead of stepping back and thinking this is not safe." SSD stated there was no IDT meeting to discuss Resident 14's discharge because she did not have time and wanted to finish Resident 14's discharge task. SSD stated, "...if I had time, I would have, but I wanted to get it done ..." The SSD acknowledged a note documented as an IDT for Resident 14's discharge dated 6/7/21 did not involve other departments' leaders from the IDT team other than SSD herself. The SSD stated the IDT team members should include the DON, ADON (assistant DON), social worker (SW), Rehab Director, dietician, administrator (ADM), MDS Coordinator, and the Activities Director. During an interview and concurrent record review with the DON on 6/14/21 at 2:47 p.m., the DON confirmed other than asking family if they would take Resident 14 to home or a homeless shelter placement, there was no documentation to indicate the facility tried to plan or attempt other options for discharge instead of the street for Resident 14. The DON confirmed the physician discharge order dated 6/4/21 indicated to discharge Resident 14 to home. The DON confirmed the physician was unaware that the facility discharged Resident 14 to the street. During a telephone interview with family member A (FM A) on 6/11/21 at 3:25 p.m., FM A stated, "He (Resident 14) was released in the condition he was in. He can barely walk and was mostly in a wheelchair." FM A stated the facility did not call her about the discharge planning and Resident 14 called FM A and informed FM A that he would be discharged from the facility. FM A stated, "The facility never asked me if I would take him into my house. I have not heard from him since he was discharged. I let them know he was too sick to go. I told them he can't even walk. There was no cooperation." Review of Resident 14's Progress Notes written by the SSD, dated 3/18/21, indicated Resident 14's RP stated she wanted the resident to be "..discharged to a safe environment and an appropriate living arrangement ..." During an interview with LVN K on 6/11/21 at 12:56 p.m., LVN K stated she did not know where Resident 14 was being discharged when she discharged him on 6/7/21, and stated she believed it to be a home as the physician's order indicated. During an interview with the facility administrator on 6/14/21 at 3:13 p.m., the ADM stated he was unaware that Resident 14 was discharged to the street and he thought Resident 14 was going to be discharged to a homeless shelter. The ADM stated the facility should have addressed Resident 14's discharge. The ADM confirmed there was no IDT meeting to discuss Resident 14's discharge. During an interview and concurrent record review with the Rehabilitation Director (RD), on 6/14/21 at 2:32 p.m., RD confirmed there was no documentation indicating the facility completed a safety assessment of the area in which Resident 14 was to be discharged. The RD confirmed there was no documentation indicating Resident 14 was assessed from lying on the ground to sitting and standing positions. The RD stated the intent of the rehabilitation therapy was not to discharge Resident 14 to the street. The RD stated Resident 14 was discharged from the rehabilitation services prior to discharge from the facility. The RD stated Resident 14 used the wheelchair frequently and indicated there was no order for a wheelchair on discharge. The RD stated "roughly" half of the time Resident 14 used a walker and half of the time Resident 14 used a wheelchair. Review of Resident 14's MDS Assessment dated 6/7/21 (when Resident 14 was discharged from the facility) indicated Resident 14 required limited assistance (staff provide guided maneuvering of limbs or other non-weight-bearing assistance) on how the resident moved to and from lying position and turned side to side. Resident 14 required extensive assistance (staff provide weight-bearing support) for dressing (putting on clothing), toilet use, and personal hygiene (combing the hair, brushing teeth, shaving, washing/drying face and hands). Review of Resident 14's MDS assessment dated 3/8/21 (when Resident 14 was admitted to the facility) indicated Resident 14 required extensive assistance with one person physical assist for dressing, toilet use, and personal hygiene. Resident 14's MDS assessments indicated Resident 14 did not improve his activity daily living (ADL, like walking, eating, dressing, toileting and personal hygiene) level of dressing, toilet use and personal hygiene and still required extensive assistance when the facility discharged Resident 14 to the street on 6/7/21. Review of Resident 14's Progress Notes written by the SSD dated 6/11/21, indicated family members had not heard from or seen Resident 14, and the facility staff were unable to find the resident in the area where he was discharged. Review of the facility's Policy and Procedure "Interdisciplinary Team Daily Clinical QA Process," dated 11/08/18, indicated the IDT team consists of the ADM, DON, Director of Staff Development (DSD), MDS Coordinator, Medical Records Director, Rehabilitation Department, Social Services, Food/Nutrition Services, and Activity staff. Review of the facility's Policy and Procedure "Discharge Summary and Plan," revised in November 2017, indicated the resident/representative will be involved in the post-discharge planning process. Review of the facility's Policy and Procedure "Discharge Summary and Plan," revised in November 2017, indicated " ...Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan ...The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: ...Where the individual plans to reside ...Arrangements that have been made for follow-up care and services ...How the IDT will support the resident or representative in the transition to post-discharge care ..