Health inspection·December 5, 2024

Brookside Care Center The following reflects the findings of the California Department of Public Health during the investigation of Complaint # CA00919049 Survey Event ID: ZGLN11 State Citation B was written. Cal. Code Regs. Tit. 22, § 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Code of Federal Regulations, Title 42, §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. Code of Federal Regulations, Title 42, Section §483.15(e)(1) (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. On 9/19/24 at 1:15 p.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding a resident discharge. The Department determined the facility failed to ensure Resident 2's rights were protected when: a. Resident 2 left the facility in the morning of 9/1/24, and upon his return in the afternoon, he was not allowed to enter the facility; b. The facility told Resident 2 he left AMA (choosing to leave against medical advice), but did not provide Resident 2 an explanation, a copy of the AMA form, or notify Adult Protective Services (APS, provides emergency intervention for vulnerable dependent adults and seniors) per their policy; and, c. Resident 2 was hospitalized on 9/1/24, and the hospital attempted to transfer him back to the facility on 9/2/24, but the facility refused to allow him to return. This failure resulted in Resident 2 waiting in the hospital for two days for placement in another facility out of the area and had the potential for Resident 2 to experience emotional distress due to leaving a familiar area. A review of Resident 2's "ADMISSION RECORD" indicated Resident 2 was admitted to the facility in the fall of 2023 with diagnoses including, but were not limited to, lower back pain, cirrhosis of the liver (permanent scarring that damages the liver and interferes with its functioning), depression (a persistent feeling of sadness and loss of interest that interferes with activities of daily living), and schizophrenia (a serious mental disorder in which a person interprets reality abnormally). A review of Resident 2's "Minimum Data Set [MDS, a federally mandated resident assessment tool] Section GG-Functional Abilities and Goals - Discharge," dated 9/1/24, indicated Resident 2 needed set up or clean up assistance with activities including eating, dressing, oral and personal hygiene. Further, the MDS indicated Resident 2 used a manual wheelchair for mobility and needed assistance to get into and/or out of the wheelchair. Review of a facility document, "Against Medical Advice (AMA) Form," dated 9/1/24, and signed by the Director of Nursing (DON) and witnessed by a Licensed Nurse, indicated, "...[Resident 2's name]...I am leaving on my own insistence and against the advice of my attending physician...I have been informed of the dangers/risks to my health...I fully understand the information that has been discussed and have been given the opportunity to ask questions..." There was no signature by Resident 2. Review of Resident 2's hospital record, "Consultation," dated 9/2/24, indicated, "...Pt [patient] is reportedly not welcome to return to [facility name] pt needs continued nursing care, Social work will need to assist with placement..." Review of Resident 2's hospital record, "Social Work Note," dated 9/2/24, indicated, "...received call from [facility staff name] ...administrator stated pt can not return..." During an interview with the San Joaquin County Long Term Care Ombudsman (OMB- advocate for residents in long term care facilities) on 9/19/24 at 2:25 p.m., the OMB stated Resident 2 borrowed an electric wheelchair from a resident (Resident 4) at the facility. The OMB stated the process for residents leaving the facility on a pass was for residents to sign out in the facility logbook and they could leave for four hours. The OMB Resident 2 signed out when he left the facility, and when Resident 2 returned, he was not allowed to re-enter the facility. The OMB stated Resident 2 called an ambulance when the facility wouldn't let him back in and called the ombudsman to appeal. During an interview with the DON on 9/19/24 at 2:45 p.m., the DON stated residents going out of the facility on a pass needed an order from their physician. The DON stated the pass was for four hours and if residents needed more than four hours, they needed an order from the physician. During an interview with Resident 4 on 9/19/24 at 3:00 p.m., outside in the facility courtyard, Resident 4 stated he loaned his electric wheelchair to Resident 2 two to three weeks ago. Resident 4 stated Resident 2 needed to go to the mall to get a new cellphone. Resident 4 stated it was difficult to travel to the mall with a manual wheelchair. Resident 4 stated Resident 2 knew how to operate his electric wheelchair and he only loaned his electric wheelchair to people he trusted. Resident 4 stated the DON returned his wheelchair to him later that day and told him Resident 2 was not returning to the facility. During an interview by phone on 9/19/24 at 3:24 p.m., Resident 2 stated he signed out in the facility logbook for going out on pass when he left the facility in the electric wheelchair which he borrowed on 9/1/24. Resident 2 stated he was not allowed to re-enter the facility when he returned that same day. Resident 2 stated facility staff did not explain, and he did not know what AMA meant. Resident 2 stated he did not sign an AMA form. Resident 2 stated he called an ambulance when he was not allowed to re-enter the facility. Resident 2 stated the ambulance took him to the acute care hospital emergency department, and he was there for about four days. Resident 2 stated that after four days the emergency department sent him to a care home in a different city. During an interview and concurrent record review on 9/19/24 at 3:35 p.m., with the facility administrator (ADM), DON, and the Assistant Director of Nursing (ADON) in the DON's office, the ADM stated Social Services was responsible for discharge orders. The ADM stated the AMA process was to talk to the resident first to avoid an AMA, if possible, then ask the resident where they were going, so APS could follow up. They would then notify the resident's physician (MD) regarding AMA and provide an opportunity for the MD to convince a resident to stay. The AMA form should be filled out and signed by the resident, and the facility sends the Ombudsman a notice of AMA. The DON confirmed Resident 2 did not sign the AMA form or receive a copy, and APS was not notified of Resident 2's AMA discharge. The DON confirmed Resident 2 did not know his rights regarding the AMA discharge. The DON stated Resident 2's MD was notified of Resident 2's AMA discharge, but confirmed there was no MD progress note regarding the event. The DON confirmed Resident 2 was not allowed to re-enter the facility when he returned that same day. The DON acknowledged that the AMA discharge was unsafe for Resident 2. The DON confirmed there was no transfer notice or discharge notice in Resident 2's medical record, and Resident 2 did not receive a copy of a transfer notice or discharge notice. During an interview with Certified Nursing Assistant 1 (CNA) 1 on 9/19/24 at 4:21 p.m., CNA 1 stated she saw Resident 2 outside when she arrived at work on 9/1/24 and Resident 2 tried to get back into the facility. CNA 1 stated Resident 2 was told he needed a MD note to be out of the facility for more than four hours, and needed a MD note to get back into the facility. CNA 1 stated that Resident 2 just stayed outside. During an interview with the Social Services Director (SSD) and the ADM on 9/20/24 at 12:35 p.m., the SSD stated that on 9/1/24 Resident 2 left in a motorized wheelchair and went AMA. The ADM stated leaving AMA was a discharge. The ADM stated when residents left the facility AMA, the facility was no longer responsible for their care, and as a result, Resident 2 was not allowed to re-enter the facility. The ADM stated Resident 2 was upset when he returned, so the police were called. The ADM and SSD agreed that Resident 2 did not receive a medication reconciliation list or discharge instructions, since he left AMA. The ADM stated that nursing needed to be consulted on whether Resident 2's MD condoned the AMA discharge. The ADM stated AMA discharges were not typically safe; that's why it was an AMA. During an interview with CNA 2 on 9/20/24 at 1:50 p.m., CNA 2 stated she was at the facility when Resident 2 left the facility in the electric wheelchair on 9/1/24. CNA 2 stated her assigned resident (Resident 4) loaned Resident 2 his electric wheelchair. CNA 2 stated that at 2:20 p.m. the DON and Licensed Nurse (LN) 2 were outside waiting for Resident 2. CNA 2 stated Resident 2 came up and the DON and LN 2 didn't let him in. CNA 2 stated Resident 2 told the DON and LN 2 that he didn't know he couldn't leave with someone else's wheelchair. CNA 2 reported the DON told Resident 2 he didn't have a pass and didn't sign out. A review of a facility document titled, "Resident Sign Out Binder", undated, indicated Resident 2 signed out of the facility on pass on 9/1/24 at 10:20 a.m. During an interview with Resident 6 on 9/20/24 at 2:15 p.m. in his room, Resident 6 stated he signed out in the facility logbook whenever he left the facility. Resident 6 stated that he could leave on his own if he came back in 4 hours. Resident 6 stated if he didn't come back in four hours, the facility would call the police, in case of an accident. Resident 6 stated he didn't need a MD order to leave; he just signed the logbook. A review of a facility policy and procedure (P&P), undated, titled, "Resident Out on Pass Procedure", undated, the P&P indicated, "...Residents sign out binder to be kept at the nurse's station. LTC residents needing to go out on pass must sign out...may not exceed a duration greater than the allotted four hours...Residents must sign back in upon returning to the facility...Residents must be in the facility prior to sundown..." A review of a facility P&P titled, "Transfer and Discharge (including AMA)", the P&P indicated, "...3. When a resident exercises his or her right to appeal a transfer or discharge, the facility will not transfer or discharge the resident while the appeal is pending...13. Discharge Against Medical Advice (AMA)...a...Under no circumstances will the facility force, pressure, or intimidate a resident into leaving AMA...b. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility...d. Notify Adult Protection Services, or other entity as appropriate..." Therefore, the Department determined the facility failed to ensure Resident 2 was permitted to return to the facility the same day after Resident 2 left the facility on a pass, Resident 2 then went to an acute care facility (hospital) and was still not allowed to return to the facility following hospitalization. This failure resulted in Resident 2 waiting in the hospital for two days for placement in another facility out of the area and had the potential for Resident 2 to experience emotional distress due to leaving a familiar area. This violation had a direct or immediate relationship to the health, safety, or security of Resident 2.