Other·October 18, 2023

Facility: Eden Valley Care Center The following reflects the findings of the California Department of Public Health during the investigation of Complaint # CA00835473 Survey Re-licensing/Re-certification) Event ID: 8RUJ11 Representing the Department, HFEN 36623 State Citation B was written F742 Treatment/Svc for Mental/Psychosocial Concerns §483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that- §483.40(b)(1) A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; Based on interview and record review, the facility failed to provide appropriate mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) treatment and care for one of three residents (Resident 1), who had a history of trauma and/or post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), from childhood trauma, from being sexually assaulted, and from the loss of her son, when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm was not followed-up prior to discharge; 4. Resident 1's psychologist (psych, a medical doctor who specializes in mental health) referral (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) was not initiated as ordered, prior to the discharge; 5. Resident 1's Preadmission Screening and Resident Review (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI, mental, behavioral, or emotional disorder), developmental disability (DD, a group of conditions due to physical impairments or impairments in the areas of learning, language, or behavior), intellectual disability (ID, condition to describe a person with limitations in the ability to learn and function), or related condition requires specialized services such as referral to a mental health authority) Level I Screening was not done prior to admission or within 30 days of admission and a PASSR Level II evaluation was not completed; 6. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a homeless shelter. Resident 1 cried because she did not want to be discharged. Resident 1 was "hysterical, crying with anxiety," and having a mental "breakdown" when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her and Resident 1 returned to the facility. Prior to her discharge, Resident 1's mental and psychological status was not evaluated as her PTSD was not assessed, her thoughts of self-harm were not followed up, and her psych referral was not initiated. Resident 1 did not receive sufficient notice prior to her discharge and was being discharged to a shelter against her wishes. These failures resulted in emotional distress in Resident 1 and caused harm to her mental and psychosocial well-being. Findings: On 4/11/23 at 10:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding discharge rights. Review of Resident 1's Order Summary Report, dated 4/11/23 indicated, the resident was a 58-year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with "PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress." Review of the progress notes, dated 12/1/21, indicated, "Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares." It also indicated Resident 1's "problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]." Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was "very important" to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, "Resident reports having thoughts of self-harm. States she does not have a plan but has self-harmed in the past ... Referred to SSD [social services designee] for f/u [follow up]." Review of Resident 1's progress notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Review of Resident 1's physician order, dated 3/29/23, indicated, "Per MD [medical doctor] start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t [related to] Anxiety Disorder, ADHD, and PTSD." There was no documentation that indicated Resident 1's psych referral was initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated staff documented that Resident 1 required supervision and set up help for activities of daily living (ADLs) including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program (activities that focus on increasing a person's level of functioning) note, dated 4/8/23, indicated, "She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt (a device used to help a person transfer or walk safely)..." Review of Resident 1's social services progress notes, dated 4/10/23, indicated the social services designee (SSD) wrote, "Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time." Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated "[Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): ... The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility." It also indicated Resident 1 signed on the notice indicating, "This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge," dated 4/11/23, the day she was discharged. Review of Resident 1's progress notes, indicated there was no documentation the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) discussed Resident 1's discharge including her thoughts of self-harm and PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, "POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS", "Resident/Family Plan for Continuing Care", "Community Services Desired", "Nursing Care Needs", "Activity Limitations", "Treatment/Special Instructions", "Nutrition/Diet Order", "Physical/Occupational Therapy", and "Activities" were left blank. The section, "Follow-up Instructions," "Appointment," and "Referral to" were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Resident 1's social services progress note, dated 4/12/23 after she returned to the facility, indicated, "Conversation held in regards to [Resident 1's] Medi-cal [California's health care program which covers most medically necessary care], she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs ... Res states she knows she reacted horrible to the leaving but it is related to her PTSD." Review of Resident 1's PASSR Level I Screening, dated 5/30/23, indicated, "Result of Level I Screening: Level I - Positive." It also indicated for the question, "Does the Individual have a serious diagnosed mental disorder...?" the responses were, "Yes" and "anxiety disorder, adhd." There was no documentation that indicated Resident 1 had a PASRR Level I assessment prior to admission or within 30 days of admission. There was no documentation that indicated Resident 1 had a PASRR Level II evaluation. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged. During an interview on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. Resident 1 also stated she was still awaiting a GI (gastrointestinal) appointment and a psych appointment. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, "[Resident 1] was crying when we were leaving." The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, "[Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]." The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take Resident 1 because she was not able to walk or look for job placement. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD (a mental health condition with similar symptoms as PTSD, but may include problems controlling emotions and feelings of worthlessness, shame and guilt) due to childhood and adult traumas, including the loss of her son and being "gang raped." Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but stated she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would "rather die than go through that." During an interview, on 7/5/23 at 1:50 p.m., Resident 1 stated she has not had a psych referral yet and expressed the need for it. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. She stated she might have missed creating Resident 1's care plan for PTSD. During an interview on 7/5/23 at 2:44 p.m., the SSD stated Resident 1 had a care plan for depression, but it should have been for PTSD. The SSD stated she did not know anything about a psych referral for Resident 1 prior to her discharge. During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be with in there and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her "being raped," she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14