Other·November 8, 2023

The following reflects the findings of the California department of Public Health during the investigation of a complaint # 852144. The inspection was limited to the specific complaint investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: HFEN # 47734 A deficiency was issued for complaint number 852144 at F-tag 624 F624 42 CFR §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was discharged home safely when Resident 1 needed assistance with personal care but was sent home alone without a caregiver or family member in an unsafe living condition and without discharge instructions. This failure resulted in Resident 1 being admitted to the hospital for 12 days with diagnoses of failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments), pulmonary edema (too much fluid in the lungs), elevated troponin (type of protein found in the muscles of the heart - indicator for impending heart attack) after only six hours from being discharged from the skilled nursing facility (SNF) and 12 days later, was referred to hospice care (end of life care). Findings: On 7/27/23, an unannounced visit was conducted at the facility to investigate a complaint regarding unsafe discharge of Resident 1. Resident 1 was a 74-year-old male resident, admitted to the facility on 6/20/23. Resident 1 had diagnoses of Need for Assistance with Personal Care, Abnormalities of Gait (manner of walking) and Mobility, Chronic Congestive Heart Failure (a serious condition in which the heart does not pump blood efficiently), Chronic Respiratory Failure (severe breathing problem), Chronic Obstructive Pulmonary Disease (COPD - severe breathing problem caused by airflow blockage). During an interview on 7/25/23 at 10:10 a.m. with Case Manager (CM), CM stated Resident 1 was brought to the emergency room because he passed out on his couch (after being discharged home on 7/22/23 from the SNF). CM stated the SNF verified the discharge plan for Resident 1 was to have a caregiver at home, but he (Resident 1) had no caregiver at home and was discharged home alone. CM stated she spoke with Resident 1's Caregiver (CG) but she stated she (CG) no longer was his (Resident 1) caregiver. CM stated Resident 1 did not have a caregiver at home when he [Resident 1] was discharged. During an interview on 7/27/23 at 2:20 p.m. with Director of Social Services (DSS), DSS stated she was unable to contact Resident 1's caregiver (CG) on the number that they (facility) had for him as an emergency contact but still Resident 1 was discharged home without a caregiver. DSS stated Resident 1 was discharged home alone. During a review of Resident 1's "Discharge Note," dated July 22, 2023, at 12 p.m., the "Discharge Note" indicated, "Patient [Resident 1] was discharged approximately at 12 p.m. via facility transport." The "Discharge Note" was reviewed. There was no documentation of discharge instructions provided to Resident 1 and no documentation if Resident 1 understood the discharge instructions. During an interview on 7/27/23 at 2:45 p.m. with Director of Nursing (DON), DON stated the facility had given Resident 1 the NOMNC (Notice of Medicare Non-Coverage - informs beneficiaries [Resident 1] of their discharge when their Medicare, government national health insurance covered services are ending). DON stated Resident 1 needed a caregiver but did not have one at home. During a review of Resident 1's "Emergency Documentation (ED)," dated July 22, 2023 at 6:05 p.m. (six hours later from being discharged from the SNF and alone at home), the "ED" indicated, "Chief Complaint: BIBA [brought in by ambulance] for 5150 [emergency 72-hour hold for mental health crisis] GD [grave disability - a condition in which a person is unable to provide for his or her basic personal needs for food, clothing, or shelter], failure to thrive, presents hypotensive [low blood pressure], and bradycardic [low heart rate] (7/22/23 6:02 p.m.). History of Present illness: Patient [Resident 1] is 74 years old male with history of hypertension [high blood pressure], diabetes [disease where sugar levels are not regulated], hyperlipidemia [high concentration of fats in blood], HFrEF [Heart Failure reduced Ejection Fraction - measurement of how much blood is pumped through the heart] 40% [30-40% Moderately Abnormal], and tobacco use who presents for altered mental status, hypotension, and bradycardia. Per EMS [Emergency Medical Services], law enforcement was called by neighbors for a wellness check. Found on his couch hypotensive SBP [systolic blood pressure - measures the pressure in your arteries when your heart beats] 90s and bradycardic HR [heart rate] 50s [normal heart rate is 60 - 100] with intermittent bouts of somnolence [feeling sleepy]. He [Resident 1] was also hypoxic [low oxygen level in the blood] on scene saturating high 70 to 80% [normal level is above 90%] and was placed on nasal cannula [tube which is placed in the nostrils to deliver oxygen for breathing]. Currently on 4 L [liters - unit of measurement], saturating 89%. 5150 GD was placed due to lack of food and air conditioning in his home. Diagnosis: Failure to thrive, pulmonary edema and increased troponin." During a review of Resident 1's "Care Plan (CP)," dated June 2023, the "CP" indicated, "Discharge Plan is: Short-term care Resident [Resident 1] wished to return home when all rehabilitation goals met and medically stable. Interventions: Assess for appropriate level of care and make recommendations. Caregiver and/or resident care training. Discuss & Assess Resident [Resident 1] and/or responsible party attitude regarding d/c [discharge] plan. Encourage relevant involvement with d/c plans. Provide adequate written and/or oral notice of all d/c plans." During a review of Resident 1's "Final Summary of the Resident's Status - Rehab (Rehabilitation) Services (FSRSRS)," dated 7/25/23, the FSRSRS indicated, "Rehabilitation Potential: Poor. Assistive Devices: Wheelchair. Additional Rehab Notes: Poor participation with therapy [rehabilitation goals not met]." During a review of Resident 1's "Admission Record," dated July 27, 2023, the "Admission Record" indicated, Resident 1 had diagnoses of: Need for Assistance with Personal Care, Abnormalities of Gait (manner of walking) and Mobility, Chronic Congestive Heart Failure (a serious condition in which the heart does not pump blood efficiently), Chronic Respiratory Failure (severe breathing problem), Chronic Obstructive Pulmonary Disease (COPD - severe breathing problem caused by airflow blockage). During a review of Resident 1's "Order Summary Report (OSR)," dated July 2023, the "OSR" indicated, "Monitor Pulse Oximetry [method of measuring the level of oxygen in a person's blood] q [every] shift: Keep SPO2 [serum pressure oxygen - measurement of oxygen level in the blood] >90%...O2 [oxygen] at 5L/min [liters per minute] via NC [nasal cannula], Continuously for COPD every shift. Resident to discharge home 7/22/23." During an interview on 8/2/23 at 12:28 p.m. with CG, CG stated she has not been his (Resident 1) caregiver since she broke her (CG) hip in 2019. During an interview on 8/3/23 at 11:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse who discharged Resident 1. LVN 1 stated she gave him his [Resident 1] medication in the bubble packs, everything that was sent from the pharmacy, she stated she was not aware of the contents of the medication bag, and she stated she did not open it. LVN 1 stated Resident 1 was alone and had no caregiver. LVN 1 verified there was no documentation of discharge instruction was provided and if Resident 1 understood the discharge instructions. During an interview on 8/8/23 at 3:03 p.m. with DSS, DSS stated, "[CG] had not been answering her phone and I am not aware that [CG] had not been his caregiver since 2019. We did not check the house, I was informed by my DON that the resident [1] was admitted to the hospital, and she [DON] said he [Resident 1] did not have an AC [air conditioning] in his house, and he had a heat stroke [heat-related illness - the body temperature rises] or something like that [sic]." During a review of Resident 1's "Minimum Data Set (MDS - comprehensive assessment tool)," dated 6/21/23, the "MDS" indicated, Resident 1's BIMS (Brief Interview for Mental Status - screening tool for cognition, ability of the brain to think) was 10 (score of 8-12 means moderate cognitive impairment). The "MDS" Section G Functional Status indicated, Resident 1 needed one-person physical assist for bed mobility, transfer, and dressing. During a review of Resident 1's hospital "Progress Notes," dated July 31, 2023, the "Progress Notes" indicated, "Patient [Resident 1] is not able to care for himself and it would be unsafe to discharge him home without someone caring for him, plan is Hospice." During a review of Resident 1's hospital "Discharge Summary (DS)," dated August 2, 2023 (Resident 1 stayed 12 days in the hospital), the "DS" indicated, "Discharge Plan: Patient [Resident 1] discharge to SNF, on Hospice." During a review of the facility's policy and procedure (P&P) titled, "Discharge Summary and Plan," dated October 2022, the P&P indicated, "The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes d. The degree of caregiver/support person availability, capacity, and capability to perform required care. f. What factors may make the resident vulnerable to preventable readmissions, and g. How those factors will be addressed." In violation of the above cited, the facility failed to safely discharge Resident 1. This failure resulted in Resident 1 being admitted to the hospital for 12 days due to grave disability after only six hours from being discharged from the skilled nursing facility. This violation presented either imminent danger that death or serious harm would result or a substantial probability of death or serious physical harm to Resident 1 and constitutes to "A" citation.