Other·October 22, 2021

The following reflects the findings of the California Department of Public Health during the investigation of: Complaints CA00753109 and CA00756736 Event ID: WFUB11 Representing the Department: HFEN # 37686 State Citation B was written §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 9/17/2021, an unannounced visit was conducted at the facility to investigate a complaint regarding Admission, Transfer & Discharge Rights. The facility failed to permit Resident 1 to return to the facility after a hospitalization, even after the Department of Health Care Services ordered the facility to readmit the resident. As a result of this failure, Resident 1 was not able to return to the place where he had resided in for multiple years. This had the potential to negatively affect the resident's psychosocial well-being. Review of Resident 1's medical record indicated he was originally admitted to the facility on 11/10/2018. The medical record indicated Resident 1 was fully vaccinated against Coronavirus 2019 (COVID-19, a new strain of virus that can cause mild to severe respiratory illness). He received the first dose of the COVID-19 vaccine on 1/18/2021 and the second dose on 2/8/2021. Review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note, dated 8/27/2021, indicated Resident 1 had right leg swelling, redness and discharge (fluid coming out of the body). The note further indicated Resident 1's doctor ordered the facility to transfer Resident 1 to the acute hospital for further evaluation. Resident 1 was transferred to the acute hospital on 8/27/2021 at 12:00 p.m. During an interview with the director of nursing (DON) on 9/17/2021, she stated the facility did not accept Resident 1 back from the acute hospital. The DON stated she did not know why the facility did not readmit Resident 1, but the facility's chief executive officer (CEO) could explain the reason. The DON also explained that Resident 1's family filed an appeal (legal challenge) to have the facility readmit Resident 1. Review of the facility's Resident List (daily census) dated 9/17/2021, indicated there were five empty beds in the facility that could accommodate male residents. There was one empty bed in Room AA, one empty bed in Room BB (this was a private room with only one bed), and one empty bed in Room CC. There were two empty beds in Room DD. During an interview with the CEO on 9/17/2021 at 1:01 p.m., she confirmed the facility did not accept Resident 1 back from the acute hospital. The CEO stated Resident 1 could not come back because the facility was not able to put Resident 1 in a room by himself (although as indicated above, there was an empty bed in Room BB, a private room). The CEO explained it was the facility's practice that any newly admitted or readmitted resident, regardless of COVID-19 vaccination status, must be isolated in their own private room for at least 10 days. The CEO explained the facility would follow this practice even though the California Department of Public Health (CDPH) and the Centers for Disease Control and Prevention (CDC) indicated that newly admitted residents who are fully vaccinated do not need to be quarantined (isolated). The CEO also added that the facility could not admit any residents into Room AA because of building safety issues (although there was a resident occupying one bed in Room AA at the time of this interview). Review of the Decision and Order (result of the family's appeal) from the Department of Health Care Services' Office of Administrative Hearings and Appeals (OAHA), dated 10/5/2021 indicated, "Facility offered arguments in support of its refusal to readmit Resident. None of its arguments constitutes a legally recognized exception to the requirement of complying with the discharge/transfer regulations when there is a refusal to readmit. Therefore, Provider's arguments do not change the outcome in this case. The appeal is GRANTED. [Facility] shall readmit [Resident 1] to his previous room if available or immediately upon the first available bed." Review of the facility's Resident List, dated 10/12/2021, indicated Resident 1 was still not back in the facility. The Resident List also indicated there were three empty beds that could accommodate male residents. There was one empty bed in Room CC, one empty bed in room DD, and one empty bed in Room EE. During an observation on 10/13/2021 at 1:16 p.m., there was still one empty bed in Room CC, one empty bed in room DD, and one empty bed in Room EE. During an interview with the CEO on 10/13/2021 at 1:20 p.m., she confirmed she was aware of the Decision and Order from the OAHA regarding the appeal to have Resident 1 readmitted to the facility. She explained she could not admit any other resident into Room CC because the resident occupying that room had Clostridium Difficile (C. Diff, an infectious disease that causes severe diarrhea). She added that due to fall risk concerns and roommate compatibility issues, the facility would not initiate room changes to free up space for Resident 1 to have a room to himself. The CEO stated the facility still would not readmit Resident 1 into a room with other residents because he needed to be isolated upon readmission. Review of the CDPH All Facilities Letter (AFL) 20-53.5, dated 8/3/2021 indicated, "Testing and quarantine is no longer required for newly admitted and readmitted residents if they are fully vaccinated and have not had prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with SARS-CoV-2 [COVID-19] infection within the prior 14 days." Review of the CDC's "Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes," updated 9/10/2021 indicated, "New Admissions and Residents who Leave the Facility: Fully vaccinated residents and residents within 90 days of a SARS-CoV-2 infection do not need to be placed in quarantine." In violation of the above cited standards, the facility failed to permit Resident 1 to return to the facility after a hospitalization, even after the Department of Health Care Services ordered the facility to do readmit the resident. As a result of this failure, Resident 1 was not able to return to the place he resided in for multiple years. This had the potential to negatively affect the resident's psychosocial well-being. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident.