Health inspection·March 11, 2022

Facility ID: 555336 District Office: Bakersfield Event ID: 4JZX11 Shari Darke, HFES Intake: 774374 Health and Safety Code section 1336.2 (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility's Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (1) Be responsible for ensuring that the resident's attending physician or the facility medical director, if the resident does not have an attending physician, completes the medical assessment of the resident's condition and susceptibility to adverse health consequences, including psychosocial effects, prior to written notice of transfer being given to the resident. The assessment shall not be considered complete unless it provides, in accordance with these assessments, recommendations for counseling, follow-up visits, and other recommended services, by designated health professionals, and for preventing or ameliorating potential adverse health consequences in the event of transfer. (2) Be responsible for ensuring that a licensed marriage and family therapist, a licensed clinical social worker, a licensed psychologist, a licensed psychiatrist, or a licensed professional clinical counselor and the facility nursing staff complete an assessment of the social and physical functioning of the resident based on the relevant portions of the minimum data set, as described in Section 14110.15 of the Welfare and Institutions Code, before written notice of transfer is given to the resident. The assessment shall not be considered complete unless it provides recommendations for preventing or ameliorating potential adverse health consequences in the event of transfer. The assessment may be amended because of a change in the resident's health care needs. The assessment shall also include a recommendation for the type of facility that would best meet the resident's needs. (3) (A) Be responsible for evaluating the relocation needs of the resident including proximity to the resident's representative and determine the most appropriate and available type of future care and services for the resident before written notice of transfer is given to the resident or the resident's representative. The health facility shall discuss the evaluation and medical assessment with the resident or the resident's representative and make the evaluation and assessment part of the medical records for transfer. (B) If the resident or resident's representative chooses to make a transfer prior to completion of assessments, the facility shall inform the resident or the resident's representative, in writing, of the importance of obtaining the assessments and follow-up consultation. (4) At least 60 days in advance of the transfer, inform the resident or the resident's representative of alternative facilities that are available and adequate to meet resident and family needs. (5) Arrange for appropriate future medical care and services, unless the resident or resident's representative has otherwise made these arrangements. This requirement does not obligate a facility to pay for future care and services. (b) The facility shall provide an appropriate team of professional staff to perform the services required in subdivision (a). (c) The facility shall also give written notice to affected residents or their representatives, advising them of the requirements in subdivision (a) at least 60 days in advance of transfer. If a facility is required to give written notice pursuant to Section 1336, then the notice shall advise the affected resident or resident's representative of the requirements in subdivision (a). If the transfer is made pursuant to subdivision (g), the notice shall include notification to the resident or resident's representative that the transfer plan is available to the resident or resident's representative free of charge upon request. (g) (1) If 10 or more residents are likely to be transferred due to any voluntary or involuntary change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility's Medi-Cal or Medicare certification, the facility shall submit a proposed relocation plan for the affected residents to the State Department of Public Health for approval at least 30 days prior to the written transfer notification given to any resident or resident's representative. The proposed relocation plan shall provide for implementation of the relocation services in subdivision (a) and shall describe the availability of beds in the area for residents to be transferred, the proposed discharge process, and the staffing available to assist in the transfers. The proposed relocation plan shall also include, but not be limited to, all of the following information: (A) The number of residents affected by the proposed closure. (B) The number of residents who do not have a legal representative and do not have the capacity to make decisions for themselves as described in Section 1418.8. (C) Attestation that each resident will undergo a medical assessment pursuant to paragraph (1) of subdivision (a) before being relocated. (D) The availability of alternative skilled nursing facility beds or other available long-term care beds within the community. (E) The reason for the proposed closure. (F) The actions the facility is taking to transfer affected residents safely and minimize possible transfer trauma. On 2/11/22, at 10:15 AM, California Department of Public Health (CDPH) conducted an unannounced state monitoring visit at the facility to ensure the safe transfer of residents related to the facility's certification termination. The facility failed to comply with the notice requirements before transferring a resident by failing to provide written notice to Resident 38's responsible party at least 60 days in advance of the transfer, and inform the resident's representative of available alternative facilities that were adequate to meet resident needs, and resident and family rights. Resident 38 was a 78 year old female, admitted to the facility on 8/4/21. Resident 38's Admission Record, dated 8/4/21, indicated the admission diagnoses included Parkinson Disease (brain disorder that leads to shaking, stiffness, difficulty with walking, balance, coordination and memory loss), Dementia (decline in cognitive/brain functions), muscle weakness and repeated falls. Resident 38's Minimum Data Set (MDS, a resident assessment tool) Section C500, Brief Interview for Mental Status Score (BIMS assesses cognitive function), dated 11/8/21, was 3 out of 15 (a score of 0 - 7 indicates severe impairment - loss of ability to reason, affects daily life functions; 8-12 indicates moderate impairment - poor decision making skills, needs reminders, cues and supervision in daily routines, 13-15 cognitively intact-no loss of decision making skills). During a review of Resident 38's physician assessment, dated 1/29/22, the physician assessment indicated, Resident 38 "does NOT have the capability to understand and make medical decisions." During a review of Resident 38's Progress Notes, dated 2/7/22, the Progress Notes indicated, "Met with the resident that will transfer today to [Receiving Facility] due to the facility ceasing to operate..." During a review of Resident 38's Notice of Proposed Transfer and Discharge, dated 2/7/22, the Notice indicated, Social Services Assistant 1 and Resident 38 signed the Notice of Proposed Transfer and Discharge on 2/7/22. During a review of Resident 38's Progress Notes, dated 2/7/22, at 2:44 PM, the Progress Notes indicated, Discharge Summary "Resident transferred to [Receiving Facility] today, picked up by [name] transportation around 12 pm via [by] wheelchair..." During a review of Resident 38's Progress Notes, dated 2/8/22, at 8:09 AM, the Progress Notes indicated, "Resident was transferred as planned to [Receiving Facility] with the intention for Return Not Anticipated. Resident's family did not agree with the transfer and requested the resident to return to our facility..." During a review of Resident 38's Progress Notes, dated 2/8/22, at 8:44 AM, the Progress Notes indicated, "Resident was transferred to [Receiving Facility] yesterday, but the resident's daughter was not happy with the transfer. The daughter wants to pursue other discharge options, so the resident was returned..." During an interview on 2/8/22, at 1:20 PM, with receiving facility Director of Nursing (DON) 2, DON 2 stated, facility transferred Resident 38 by medical transport van before lunch on 2/7/22. DON 2 stated, transferring facility DON 1 called receiving facility DON 2 at home between 5 PM and 6 PM and said to transfer Resident 38 back. DON 2 stated, DON 1 said the family did not want Resident 38 at the receiving facility. During an interview on 2/8/22, at 1:35 PM, with receiving facility LVN 1, LVN 1 stated, the receiving facility admitted Resident 38 on 2/7/22, at 12:13 PM. LVN 1 stated, Resident 38 was fine about being there. During an interview on 2/8/22, at 1:45 PM, with receiving facility LVN 2, LVN 2 stated, "She (Resident 38) left at 5:08 PM by medical transport van. I spoke with DON 2, and DON 2 said to transfer Resident 38 back to the transferring facility. During an interview on 2/8/22, at 2:52 PM, with DON 2, DON 2 stated, the transferring facility prepared the transfer packets. "We never spoke with the family. The [transferring facility] told us everything was OK." During an interview on 2/11/22, at 12:45 PM, with Vice President Behavior Health Consultant, Vice President Behavior Health Consultant stated, Resident 38's family was not notified before the transfer. The Responsible Party should have been notified prior to discharge transfer. During a concurrent record review and interview on 2/11/22, at 12:59 PM, with Regional Resource Nurse, Resident 38's physician notes were reviewed. Regional Resource Nurse stated, Resident 38 did not have capacity to sign the discharge/ transfer document for herself. Regional Resource Nurse stated, Resident 38's Responsible Party/family should have been notified and they should have given their consent for the transfer. During a concurrent interview and record review on 2/11/22, at 1:36 PM with Social Services Assistant 1, Resident 38's Notice of Proposed Transfer and Discharge was reviewed. Social Services Assistant 1 stated, she had Resident 38 sign the Notice of Proposed Transfer and Discharge. Social Services Assistant 1 stated, she was not aware of Resident 38's BIMS or if Resident 38 had the capacity to sign for herself. Social Services Assistant 1 stated, she did not check to see if Resident had the capacity to sign for herself. Social Services Assistant 1 stated, she had no training on transfer and discharging of residents. Social Services Assistant 1 stated, she was not familiar with the transfer and discharge policy. Social Services Assistant 1 stated, the facility did not have a Social Services Worker. During a concurrent record review and interview on 2/11/22, at 2:40 PM, with Regional Resource Nurse, Social Service Assistant 1 and Social Service Assistant 2 personnel files were reviewed. Regional Resource Nurse stated, the facility did not currently have a full-time social worker. Regional Resource Nurse stated, the facility hired Social Services Assistant 2 on 11/23/21, and Social Services Assistant 2 on 1/6/22. Regional Resource Nurse reviewed both Social Services Assistants' Orientation Records, and stated the Orientation Records were blank, except for the employee and Administrator signatures. Regional Resource Nurse was unable to provide written documentation the facility trained either Social Services Assistant 1 or Social Services Assistant 2 on transfer and discharge of residents. Facility was unable to provide documentation of Social Service Assistant certification for either Social Services Assistant. During an interview on 2/23/21, at 5:15 PM with Resident 38's Family Member (FM), FM stated, the facility did not discuss transferring Resident 38 to the receiving facility with her. FM stated, she received a call informing her Resident 38 was at the receiving facility. FM stated, she did not want Resident 38 at that facility. FM stated, she got a call from [Vice President Behavior Health Consultant], who apologized and offered to bring Resident 38 back to the transferring facility. During a review of Facility 1's Accepted Relocation Plan, accepted by the Department 2/2/22, the Accepted Relocation Plan indicated, "3. The resident or the resident's representative will be included in determining the resident's new location. Evaluate, prior to written notice of transfer being given to the resident or the resident's representative...The facility shall discuss the evaluation and the medical assessment with the resident or the resident's representative ... 5. Inform, at least 60 days in advance of the transfer, the resident or resident's representative of alternative facilities that are available and adequate to meet resident and family needs...9. The facility provided written notice on 2/2/2022 to the affected residents or their representatives, advising them of the requirements in subdivision (a) of Health and Safety Code [paragraph] 1336.2 at least 60 days prior to transfer..." In violation of the above cited standards, the facility failed to comply with notice requirements before transferring a resident by failing to provide Resident 38's responsible party written notice at least 60 days in advance of transfer and inform the resident's representative of available alternative facilities that were adequate to meet resident's needs, and resident and family's rights. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and is a Class A citation.