Health inspection·October 19, 2022

F626 Permitting Residents to Return to Facility Section 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. This citation is written as a result of complaint #CA00781725. An unannounced visit was made to the facility on 4/22/22 to investigate an allegation of refusal to readmit. The Department determined the facility failed to readmit Resident 1 after the resident was cleared by the physician for readmission to the facility from the General Acute Care Hospital (GACH). This failure resulted in the resident's prolonged hospital stay and increased the potential to cause emotional distress to Resident 1. Review of Resident 1's "Admission Record", indicated that Resident 1 was in her early 80's and was admitted to the facility from the Acute Care hospital on 4/18/22 with diagnoses of Urinary Tract Infection (UTI) and history of Dementia. Review of the "Order Summary Report", indicated the MD ordered medication and treatment dated 4/18/22 and signed by Licensed Nurse (LN)1. Review of the "Medication Administration Record", indicated, on 04/18/22 at 4:30 p.m., Resident 1's blood sugar was 328. Resident 1 received 7 units of Insulin. In an interview on 4/27/22 at 10:52 a.m., Licensed Nurse 1 (LN 1) stated that Resident 1 arrived around 5:00 p.m., and she checked the blood sugar and gave insulin around 5:15 pm. Review of the "Progress Notes" 4/18/22 at 9:45 p.m., written by LN1 , indicated Resident 1 was asleep at the time of arrival to the facility at 5:00 p.m. and was unable to be awakened. Resident 1 received blood sugar check and insulin as per MD orders. Resident 1 was observed 45 minutes later without clothes on her upper body, wandering in the hallway, combative and going into other residents' rooms and hitting staff. The notes described the Resident as "hard to redirect, aggressive.... was not redirectable." Emergency Medical Services was called, and the Responsible Party (RP) was made aware by phone voice message. Resident 1 was sent to hospital. The Nurse Practitioner (NP) was made aware by non-urgent communication. Review of the facility's clinical records revealed no documented evidence that the doctor was notified prior to sending Resident 1 out to the GACH 2. The NP was called after the fact and left message on a non-emergency line. There were no notes from the Social Services about the discharge to the GACH 2 or any documentation that would state the reason for no readmission. There was no documentation in Resident 1's chart physical or electronic about the rationale for not taking her back to the facility. In an interview on 4/26/22 at 10:26 a.m., the Director of Nursing (DON) stated that when Resident 1 arrived at the facility, she was sleeping. A sternal rub was done, and the resident did not wake up. There was no assessment done at that time. The nurse called out Resident 1's name and Resident 1 responded. The LN 1 obtained a blood sugar check and gave insulin at this time. Resident 1 went back to sleep. She woke up around 45 minutes later and started wandering in the hallway with no clothes on her upper body. Staff tried to redirect her, but the resident started arguing. Resident 1 could not be redirected, so the nurse called Emergency Services. LN 1 called the RP and left a message and called the NP on non-urgent line and left message. The DON stated that Resident 1 did not harm another resident or strike another resident and did not hit staff. Nurses did not call the MD or the NP to get orders for any intervention when the resident became agitated. In an interview on 4/27/22 at 10:52 a.m., LN 1 stated that when Resident 1 arrived at the facility at 5 p.m., Resident 1 was snoring. LN 1 went into Resident 1's room to assess her after the EMT (Emergency Medical Technician) transferred her to the bed and Resident 1 was asleep. LN 1 stated she went to get another nurse and they did sternal rub and Resident 1 woke up and responded. Resident 1 replied yes when she called her name. LN 1 then asked her if she wanted dinner and Resident 1 refused. LN 1 checked Resident 1's blood sugar and gave her insulin. Forty-five minutes later, the staff saw her come out of her room and she was disrobed from the waist up. When LN 1 first saw Resident 1 without her shirt, she asked her to put her clothes back on. Resident 1 tried to move staff away from her with her hand gestures, but she did not physically strike any staff. Resident 1 was combative, and staff could not redirect her, so staff called Emergency Medical Services. LN 1 stated that she did not see Resident 1 strike or hurt other residents or staff. In an interview on 4/27/22 at 12:09 p.m., LN 2 stated that, Resident 1 was in the facility before the dinner trays started coming out between 4:45-5:00 pm. In an interview with Staff 1 on 4/27/22 at 2:07 p.m., Staff 1 stated Resident 1 did not hit any, staff, or any resident. Staff 1 further stated that the facility will not accept Resident 1 back to the facility after being cleared for discharge from GACH. Staff 1 stated that the reason for not accepting Resident 1 back to the facility was she was wandering in the facility and her profile did not match what was told to Staff 1 prior to Resident 1's admission to the facility. Staff 1 stated that she was told that Resident 1 did not have any behavioral issues and that is why she accepted Resident 1's admission. In an interview on 4/27/22 at 3:56 p.m., Certified Nurse's Assistant (CNA) 1, stated that Resident 1 arrived via gurney around 5 p.m. while the trays were being passed. In an interview with Staff 2 on 06/21/22 at 9:00 a.m., Staff 2 stated that Resident 1 had been placed at another skilled nursing facility on 5/9/22. Resident 1 remained at GACH 2 for 21 days after cleared for discharge. In an interview with LN 2 (from Skilled Nursing Facility 2) on 06/21/22 at 9:30 a.m., LN 2 stated that Resident 1 was alert and oriented times 1 to 2, had occasional confusion, as she had diagnosis of dementia. Resident 1 did not have behavioral or wandering issues. A review of the facility policy titled, "Bed hold", revised 2019, indicated that, "...If the facility denies a bed-hold/readmission for a resident, the nurse supervisor/charge nurse/social service/designee will document the reason for denying the bed-hold and that the resident's primary care physician was notified of this and is in agreement with the decision to not readmit the resident to the facility. Social Services will document that the resident/legal representative was notified of the decision to not re-admit the resident and that a Notice of Proposed Transfer /Discharge was provided upon transfer..." A review of the facility's policy titled "Transfer/Discharge Policy and Procedure", revised May 2021, indicated, "...The facility may not transfer or discharge the resident without their consent unless: a. The transfer or discharge is necessary for the resident's welfare and the facility cannot meet the resident's needs 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; The health of individuals in the facility would otherwise be endangered...." Therefore, the Department determined the facility failed to readmit Resident 1 after resident was cleared by the Doctor at GACH 2 for readmission to the facility. This violation had a direct or immediate relationship to health, safety, or security of Long-Term Care patients or residents.