Other·August 31, 2023

The following reflects the findings of the California Department of Public Health during the investigation of the complaints CA00834969 and CA00841567. Event ID: OZM211 Exit date: 8/22/23 Representing the Department: Health Facilities Evaluator Nurse, 46552 State Citation B was issued. F623 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. On 4/7/23 at 2 p.m. and 5/19/23 at 9:44 a.m., the unannounced visits were conducted at the facility to investigate two complaints regarding Admission, Transfer & Discharge Rights. The facility failed to ensure to notify four residents (Resident 1, 2, 3 and 4) regarding the transfer reasons when these four residents transferred from the long-term care Skilled Nursing Facility (LTC-SNF, refers as transferring SNF, LTC-SF: a nursing facility which provides 24-hours skilled nursing care for the residents who reside in the facility for a long term) to another long-term care SNF (refers as receiving SNF) even though these residents' needs, and services could be met at this transferring SNF. These residents did not endanger themselves or the other residents' safety in the transferring SNF. In addition, the facility failed to notify six residents (Resident 1,2,3,4,5, and 6) in writing at least 30 days prior to the transfer/discharge. All these six residents had resided in the transferring SNF for more than 30 days. The facility also failed to advise all six residents of their rights to appeal regarding the transfer/discharge timely. When: 1.Resident 1 verbalized she was "sad and cried" when she left the transferring SNF to the receiving SNF. Resident 1 stated she "kept on" telling the staff from transferring SNF that she did not want to go (to the receiving SNF). Resident 1's representative (RP- resident's legal guardian, an individual acting on behalf of the resident) did not receive the transfer notice 30 days prior to the transfer. 2.Resident 2 verbalized staff from the transferring SNF told her to "get into the van" and dropped her at the receiving SNF without explaining the reason for her transfer. Resident 2 stated she was "sad and mad" about the way the transferring SNF handled her transfer. Resident 2 did not receive the transfer notice 30 days prior to the transfer. 3. Resident 3 verbalized he was "angry" at the transferring SNF and "emotionally felt sad" when he left the transferring SNF. Resident 3 did not receive the transfer notice 30 days prior to the transfer. 4. Resident 4's RP stated she did not ask for Resident 4's transfer from the transferring SNF. Resident 4's RP did not receive transfer notice 30 days prior to Resident 4's transfer. 5.Resident 5's RP did not receive transfer notice 30 days prior to the Resident 5's transfer. 6.Resident 6 did not receive discharge notice 30 days prior to his discharged home. These transfers and discharge had caused significant emotional distress to three residents (Resident 1, 2, and 3). Resident 1 verbalized she was "sad and cried" when she left the transferring SNF to the receiving SNF. Resident 2 stated she was "sad and mad" about the way the transferring SNF handled her transfer. Resident 3 verbalized he was "angry" at the transferring SNF and "emotionally felt sad" when he left the transferring SNF. These transfers and discharge had potential to violate the six residents' (Resident 1, 2, 3, 4, ,5, and 6) rights to appeal for their transfers and discharge. 1.Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 1 admitted to the transferring SNF on 1/18/2023 with diagnoses including parkinson's disease (a disorder of brain and spinal cord [begins at the bottom of the brain and ends in the lower back] that affects movement, often including tremors), tourette's disorder (a nervous system disorder involving repetitive movements or unwanted sounds), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and obsessive-compulsive disorder (unreasonable thoughts and fears that lead to repetitive behaviors). She had an assigned RP. Resident 1 transferred to the receiving SNF on 3/14/2023 and readmitted from the receiving SNF to transferring SNF on 4/11/2023. Review Resident 1's minimum data set (MDS, an assessment tool), dated 1/20/2023, indicated, Resident 1's BIMS (brief interview for mental status) score was 11 of 15 (score of 8-12: moderately impaired cognition). Review of Resident 1's physician order, dated 3/13/2023, indicated, to discharge Resident 1 to the receiving SNF. Review of Resident 1's physician order, dated 4/11/2023, indicated, to admit Resident 1 to the transferring SNF. Review of Resident 1's "Notice Of Proposed Transfer Discharge", dated 3/13/2023, indicated, to transfer Resident 1 to the receiving SNF on 3/14/23. Resident 1's RP signed the transfer notice on 3/14/23, the same day when Resident 1 was transferred to the receiving SNF. The transfer notice indicated the reason for Resident 1's transfer/discharge was "RP and resident choice to transfer to another facility". During an observation and interview with Resident 1 in the resident's room at the transferring SNF on 5/19/2023 at 12:30 p.m., Resident 1 was lying in the bed. Resident 1 stated she was "sad and cried" when she left the transferring SNF to the receiving SNF. Resident 1 also stated she kept on telling the transferring SNF case manager (CM) who was also a licensed vocational nurse (LVN) that she (Resident 1) did not want to go (to the receiving SNF), but CM did not listen to Resident 1's request and her cry. Resident 1 stated she was told by the CM that there was no permanent bed for her to stay in the transferring SNF and she had to go (to the receiving SNF). Resident 1 further stated the social service director (SSD) did not give her "any choice" other than going to the receiving SNF. Resident 1 stated she had "difficult time" adjusting and staying away from her family when she was in the receiving SNF. She stated she requested for an Ombudsman (advocate for residents and their families in skilled nursing facility) to help her to go back to the transferring SNF. Resident 1 stated she was "happy" when she went back to the transferring SNF, and she was able to see her family every day. During an interview with Resident 1's RP over the telephone on 5/19/2023 at 12:45 p.m., RP confirmed she did not request the transferring SNF to transfer Resident 1. The RP (RP is one of Resident 1's family members) stated Resident 1 called the RP and told the RP that she (Resident 1) did not want to go to the receiving SNF. RP stated Resident 1 "cried" over the phone before she left from the transferring SNF to the receiving SNF. RP also stated staff from the transferring SNF informed her the day before Resident 1's transfer that the reason to transfer Resident 1 was because "there was no permanent bed" for Resident 1 to stay in the transferring SNF. RP stated she signed the transfer notice on the same day on 3/14/23 when Resident 1 was transferred to the receiving SNF. RP further stated Resident 1 "missed seeing her family, sad and cried" every time when the RP visited Resident 1 in the receiving SNF or whenever Resident 1 called RP. During an interview with certified nursing assistant A (CNA A) at the transferring SNF on 5/19/2023 at 2:17 p.m., CNA A stated Resident 1 "cried" before Resident 1 left the transferring SNF and Resident 1 told CNA A that she (Resident 1) did not want to go to the receiving SNF and wanted to stay in transferring SNF. CNA A further stated upon Resident 1's return to the transferring SNF, Resident 1 told CNA A that she (Resident 1) was "happy" to come back to the transferring SNF. During an interview with CNA B at the transferring SNF on 5/19/2023 at 2:32 p.m., CNA B stated Resident 1 gave her a hug and "cried" when Resident 1 left the transferring SNF. Resident 1 told CNA B that she (Resident 1) did not want to go to the receiving SNF. CNA B also stated Resident 1 told CNA B the transferring SNF sending Resident 1 away from the resident's family. CNA B further stated Resident 1 was "happy" when she (Resident 1) came back to the transferring SNF. CNA B stated Resident 1 told her that Resident 1 was "sad, cried, and missed seeing" her family while Resident 1 was in the receiving SNF. During an interview with Ombudsman over the telephone on 5/23/2023 at 10:46 a.m., Ombudsman stated Resident 1 requested Ombudsman to help her to go back to the transferring SNF when she (Ombudsman) visited Resident 1 in the receiving SNF. During an interview with CNA C at the transferring SNF on 6/19/2023 at 10:30 a.m., CNA C stated Resident 1 was alert to the name, place, and time. CNA C further stated Resident 1 was able to participate in the conversation with staff and Resident 1 was able to tell staff of her needs. During an interview with licensed vocational nurse D (LVN D) at the transferring SNF on 6/19/2023 at 10:40 a.m., LVN D stated Resident 1 was alert to the name, place, time, and situation. LVN D further stated Resident 1was able to communicate her needs, express her feelings, and emotions with staff. During an interview with Resident 1's assigned nurse practitioner (NP- clinician with clinical expertise in diagnosing and treating health conditions) at the transferring SNF on 6/19/2023 at 11:45 p.m., NP stated she was not involved with discharge/transfer planning for Residents, and she was the last one to know why and where residents were transferred. She also stated Resident 1 was alert to the name, place, and time. NP further stated Resident 1 was able to communicate her needs and express her feelings with staff. Review of Resident 1's medical record, there were no documents indicated Resident 1 endangered herself and other residents in the transferring SNF. There were no documents indicated Resident 1's needs and services could not be met at the transferring SNF. 2. Review of Resident 2's face sheet indicated, Resident 2 admitted to the transferring SNF on 9/30/2021 with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in brain), depression, diabetes type 2 (a chronic condition the body either does not produce enough insulin [a hormone which regulates the amount of glucose in the blood], or it resists insulin), and cirrhosis of the liver (a chronic liver damage from variety of causes leading to scarring and liver failure). Resident 2 was her own RP. Resident 2 was transferred to the receiving SNF on 3/17/2023. Review of Resident 2's MDS assessment, dated 6/21/23, indicated, Resident 2's BIMS score was 15 of 15 (score of 13-15: intact cognition). Review of Resident 2's physician orders, dated 3/17/2023, indicated, to discharge Resident 2 to the receiving SNF on 3/17/2023. Review of Resident 2's "Notice Of Proposed Transfer Discharge", dated 3/17/2023, indicated, Resident 2 signed the transfer notice on 3/17/2023, the same day when Resident 2 was transferred to the receiving SNF. The transfer notice indicated the reason for the transfer/discharge was "Resident choice to transfer." During an observation and interview with Resident 2 in the resident's room at the receiving SNF on 6/20/2023 at 10:35 a.m., Resident 2 was observed lying in the bed. Resident 2 stated staff from the transferring SNF told her to "get into the van" and then dropped Resident 2 at the receiving SNF without explaining to her (Resident 2) the transfer reason. Resident 2 stated she was "sad and mad" about the way the transferring SNF handled her transfer. Resident 2 stated that she had "difficult time" to adjust to the receiving SNF. Resident 2 further stated she did not request or give consent to the transferring SNF for her transfer "any time" during her stay in the transferring facility. During an interview with CNA E at the receiving SNF on 6/20/2023 at 11:06 a.m., CNA E stated Resident 2 told her that Resident 2 was "sad" because the transferring SNF moved her (Resident 2) to the receiving SNF without talking to her (Resident 2) regarding her transfer. CNA E also stated Resident 2 was in the room "most of the time" and had "difficulty" adjusting to the receiving SNF when she (Resident 2) was new to the receiving SNF. During an interview with LVN F at the receiving SNF on 6/20/2023 at 1:03 p.m., LVN F stated Resident 2 was "crying" when Resident 2 was new to the receiving SNF. LVN F stated Resident 2 had "difficult time" adjusting in the beginning to the receiving SNF. Review of Resident 2's medical record, there were no documents indicated Resident 2 endangered herself and other residents in the transferring SNF. There were no documents indicated Resident 2's needs and services could not be met at the transferring SNF. 3.Review of Resident 3's face sheet indicated, Resident 3 admitted to facility on 10/06/2022 with diagnoses