Health inspection·March 2, 2023

F0660 Discharge Planning Process Section 483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. On 12/19/22 at 11:50 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding an unsafe and inappropriate discharge. Resident 1 was discharged from the facility with a suprapubic catheter (a tube inserted through the skin, into the bladder to drain urine) to a shelter on 9/7/22 without a guaranteed bed which resulted in Resident 1 living on the streets without shelter during a heat wave and being readmitted to the hospital on 9/30/22 for a urinary tract infection. The facility failed to ensure a smooth and safe discharge back to the community when Resident 1 was dropped off at a shelter during a period of extreme heat without secured lodging. A review of an admission record indicated Resident 1 was admitted to the facility on 8/1/22 with diagnoses which included shortness of breath, abnormalities of gait and mobility, and urinary retention. A review of a Minimum Data Set (MDS, an assessment tool) dated 8/8/22 indicated Resident 1 had no memory problems, inattention, nor disorganized thinking. A review of a care plan created on 8/15/22 indicated, "The [Resident 1] wishes to Discharge to the Community when goals have been met...Interventions...Make arrangements with required community resources to support independence post-discharge..." A review of a notice of proposed discharge dated 9/2/22 indicated Resident 1 was notified on 9/2/22 of his discharge to a community shelter on 9/7/22 because his health had improved sufficiently so he no longer required services provided by the facility. The document also indicated Resident 1 refused to sign the document. A review of Resident 1's nurses progress note dated 9/7/22 at 1:56 p.m. indicated, "Discharge instructions given to resident verbalized/ expressed understanding. Discharged to home with current medications. Picked up at [1:50 p.m.] via white cab." A review of Resident 1's social services progress note dated 9/7/22 at 4:14 p.m. indicated, "[Resident 1] has completed goals and is safe to discharge. [Resident 1] requested to Discharge to Homeless Shelter. SSD arranged transport to the Homeless Shelter that Resident requested to DC [discharge] to." A review of Resident 1's progress notes created between 8/7/22 and 9/7/22 indicated one social service note in which discharge planning had been discussed. A review of a social services progress note created on 9/15/22 at 2:51 p.m. with an effective date of 9/2/22 at 2:47 p.m. indicated, "SSD [Social Service Director] and Assistant Administrator met with [Resident 1] and discussed Discharge Plan. Resident has completed goals and is safe to DC to the Community on 9/7/22. Resident states he prefers to go to a Homeless Shelter...Resident is scheduled to DC 9/7/22." In an interview on 12/19/22 at 1:14 p.m., the SSD stated her responsibility in the process of a resident discharge was to ensure a smooth and safe discharge to home or another facility. The SSD stated she called the community shelter and was told beds were available, but they were on a first-come, first-served basis. The SSD also stated she did not document what date she called the community shelter nor whom she spoke with. In an interview on 12/19/22 at 1:35 p.m., the Assistant Administrator (AA) stated he expected staff to document when, who, and what was discussed when staff contacted other facilities during the discharge process. The AA also stated he expected facility staff to ensure Resident 1 got a bed at the shelter. In an interview on 12/19/22 at 1:50 p.m., Resident 1 stated when he arrived at the shelter, the shelter staff told him they had no idea who he was and denied they spoke to anyone to secure him a bed because, "that was not how it was done." Resident 1 confirmed he refused to sign the discharge paperwork and was not provided a copy of the paperwork until the day he was discharged. Resident 1 stated he wanted to appeal but was given the instructions on how to appeal an hour before transportation came to pick him up. Resident 1 stated the SSD told him she would make arrangements for him to secure a bed at the shelter. Resident 1 also stated because he did not have a bed at the shelter, he ended up living on the streets for three weeks during a heat wave before he passed out and was sent back to the hospital. In an interview with a representative at 2-1-1 Sacramento (a free confidential information and referral service provided to the public within the Sacramento area) on 12/19/22 at 3:25 p.m., the Referral Specialist 1 (RS 1) stated a shelter survey must be completed when a person plans to discharge from a skilled nursing facility to a shelter. The RS 1 stated the shelter survey assesses the needs and accommodations required for a placement to the appropriate shelter. Once the survey is completed, the person is placed in a queue for placement. The typical timeframe for the shelter survey and placement into a shelter is three months. The RS 1 also stated, "There is a zero percent chance a person from a nursing facility can call a shelter directly and get a guaranteed bed on the spot." The shelter survey is required and can only be accessed via the Homeless Management Information System database. There are only three shelters in Sacramento which allow for overnight-stays. These shelters are on a first-come, first-served basis. Two of the shelters open at 7 p.m. and the other opens at 8 p.m. The RS 1 stated, "In order to get a good chance at securing a bed, most people must get in line at least one hour before doors open." In events of extreme weather, Sacramento also has day-shelter locations, but these are only open during the day and are offered temporarily during times of extreme weather. In an interview on 12/19/22 at 4:17 p.m., the Transportation Service Representative (TSR) confirmed the SSD called the transportation company to schedule a ride for Resident 1 at approximately 3 p.m. The TSR stated Resident 1 was picked up at 4:10 p.m. and was dropped off to a determined location at approximately 4:30 p.m. A review of the National Weather Service's climatological data for the Sacramento area indicated: -On 9/6/22, Sacramento had a maximum temperature of 114 degrees Fahrenheit (F, a measure of temperature) and a minimum temperature of 73 F; -On 9/7/22, a maximum temperature of 107 F and a minimum temperature of 73 F; and, -On 9/8/22, a maximum temperature of 112 F and a minimum temperature of 68 F. A review of the facility's policy and procedure titled "Discharging the Resident", revised December 2016, indicated, "...Preparation...The resident should be consulted about the discharge...Discharges can be frightening to the resident. Approach the discharge in a positive manner...Assess and document resident's condition at discharge...if medical condition allows...The following information should be recorded in the resident's medical record...If the resident refused the discharge, the reason(s) why and the intervention taken..." A review of the facility's document titled "Notice of Proposed Transfer/ Discharge" dated 9/2/22 indicated, "...If you believe that the proposed transfer/ discharge is inappropriate in your case, and is involuntary, you have the right to appeal...If you intend to file an appeal...it is suggested that you do so within (10) ten calendar days of being notified. The decision regarding an appeal will normally be made within thirty (30) working days from the date you were formally notified...You should be aware that the decision to transfer/ discharge may be upheld; if this is the case, you should be prepared to transfer/ discharge at the end of the (30) days from the date you were formally notified." In violation of the above cited standards, the facility failed to implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Therefore, the facility failed to ensure a smooth and safe discharge back to the community when Resident 1 was dropped off at a shelter during a period of extreme heat without secured lodging. This violation had a direct and immediate relationship to the health, safety, and security of Resident 1.