Health inspection·March 29, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint #CA00878114 Event ID: DH0M11 Representing the Department: HFEN # 47369 State Citation B was written. Health and Safety Code 1599.1 (h)(1) If a resident of a long-term health care facility has been hospitalized in an acute care hospital and asserts his or her rights to readmission pursuant to bed hold provisions, or readmission rights of either state or federal law, and the facility refuses to readmit him or her, the resident may appeal the facility's refusal. (2) The refusal of the facility as described in this subdivision shall be treated as if it were an involuntary transfer under federal law, and the rights and procedures that apply to appeals of transfers and discharges of nursing facility residents shall apply to the resident's appeal under this subdivision. (3) If the resident appeals pursuant to this subdivision, and the resident is eligible under the Medi-Cal program, the resident shall remain in the hospital and the hospital may be reimbursed at the administrative day rate, pending the final determination of the hearing officer, unless the resident agrees to placement in another facility. 42CFR §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. On 1/5/24 an unannounced visit was made to the facility to investigate an allegation of a refusal to readmit a resident (Resident 1). The Department determined the facility failed to permit Resident 1 to return to the facility after hospitalization in violation of the resident's right. On 11/11/23, Resident 1 was ready to return to the facility after one day of hospitalization, but the facility refused to readmit Resident 1. This failure had the potential to cause emotional distress and/or harm to Resident 1, who was a long-term resident of the facility. Resident 1 was admitted to the facility in July of 2023 with diagnoses which included unspecified cirrhosis of the liver (a disorder in which the liver is scarred or permanently damaged) and chronic pain syndrome. During a telephone interview on 1/5/24, at 8:03 AM, the Ombudsman (OMB) stated there had been a conflict between Resident 1 and the facility. The OMB further stated the facility contacted law enforcement, and Resident 1 was sent to an acute care hospital (GACH). The OMB stated hospital staff talked to the Administrator (ADM) and the social services department and they refused to accept Resident 1 back. During a telephone interview on 1/5/24, at 11:10 AM, the hospital Case Manager (CM), stated Resident 1 was transferred to the hospital on 11/10/23. The CM further stated the facility reported Resident 1 was throwing food at them and they were sending him out. The CM stated the facility was told the transfer was inappropriate, but they would not take him back. The CM further stated, "...they dumped him..." The CM stated Resident 1 remained at the hospital until they could find him alternate placement which occurred on 11/14/23. During an interview on 1/10/24, at 9:28 AM, the OMB stated Resident 1 had been upset because he still had belongings at the facility and the facility did not want him back. During an interview on 1/12/24, at 12:31 PM, the OMB stated during a visit with Resident 1 on 1/10/24, he stated he had wanted to return to the facility after his hospital stay to be closer to his family and because he liked the atmosphere there. A review of Resident 1's GACH (General Acute Care Hospital) clinical record, "Orders," indicated a physician order was written on 11/11/23 to discharge Resident 1. A review of Resident 1's GACH clinical record, "CLINICAL SOCIAL WORK PROGRESS NOTE" dated 11/14/23, indicated, "Consulted with [CM name] and SW [Social Work] Manager...for abandonment by [Skilled Nursing Facility Name]..." A review of Resident 1's GACH clinical record, "FINAL CASE MANAGEMENT NOTE," dated 11/14/23, indicated, "[Resident 1] will discharge to [name of an alternate skilled nursing facility]..." During a concurrent interview and record review on 1/5/24, at 11:28 AM, the Social Services Director (SSD), stated Resident 1 requested to be sent to the hospital, he said he was in pain, and we were not providing him care. The SSD further stated they had been discussing his behaviors and decided to call the police. The SSD stated the police called the fire department because Resident 1 was in pain. The SSD confirmed there was no documentation in Resident 1's EHR regarding the transfer or discharge. The SSD further stated they did not accept Resident 1 back to the facility because he was not appropriate, he was rude to his roommate and his behaviors put other residents at risk. The SSD confirmed there was no documentation of referrals for psychiatric services or of IDT (interdisciplinary team, group of health care professionals from different disciplines who assess and coordinate care) meetings regarding his behaviors. During an interview on 1/5/24, at 12:18 PM, Licensed Nurse (LN) 1 stated during her shift on 11/10/23, Resident 1 had asked for pain medication. LN 1 further stated she administered the medication and then after 30 minutes Resident 1 was screaming and talking to social services. LN 1 stated the Administrator (ADM) went into Resident 1's room and then the police were called. LN 1 stated she did not see Resident 1 after that. During a concurrent interview and record review on 1/5/24, at 12:42 PM, LN 2 stated Resident 1 did not want to go with the police he wanted to go to the hospital instead. LN 2 confirmed Resident 1's EHR did not have a physician order for transfer/discharge to the hospital. LN 2 further confirmed there was no documentation in Resident 1's EHR regarding his transfer to the hospital. During an interview on 1/5/24, at 1:09 PM, the ADM stated the hospital was upset that they transferred Resident 1 to them. The ADM further stated Resident 1 had been hostile and verbally aggressive which prompted them to call the police. The ADM stated they had every indication that Resident 1 would leave with the police but Resident 1 demanded to go to the hospital. The ADM confirmed there was no documentation regarding Resident 1's transfer to the hospital. A review of Resident 1's admission document titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities," dated July 5, 2023, indicated, "...Bed holds and Readmission...If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed..." The form was electronically signed by Resident 1 on July 5, 2023. A review of Resident 1's document titled, "BED HOLD NOTIFICATION," dated 11/10/23 indicated, "...confirmation of transfer & bed hold provision...transferred to [line was blank]...on 11/10/23 at 1:45..." The form indicated Resident 1's daughter was notified on 11/10/23 at 2 PM of the bed hold notification by the ADM. A review of a facility policy and procedure (P&P) titled, "Transfer or Discharge Documentation," revised December 2016, indicated, "...When a resident is transferred or discharged, details of the transfer or discharge will be documented in the medical record...Each resident will be permitted to remain in the facility, and not be transferred or discharged unless...the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility...When a resident is transferred...the following information will be documented in the medical record...The basis for transfer or discharge...the specific resident needs that cannot be met...the facility's attempt to meet those needs...the receiving facility's service(s) that are available to meet those needs...the date and time of the transfer or discharge...the new location of the resident...the mode of transportation...A summary of the resident's overall medical, physical and mental condition..." Therefore, the Department determined the facility failed to readmit Resident 1 after the GACH physician ordered Resident 1's discharge on 11/11/23. As a result, Resident 1 underwent unnecessary prolonged hospitalization while placement was found and on 11/14/23, Resident 1 was sent to an unfamiliar facility. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.