Other·August 20, 2021

F626 CFR §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 6/4/21, an unannounced visit was conducted at the facility to investigate three complaints regarding the facility’s refusal to re-admit Resident 1 following a four-day hospital admission for a fractured (broken) hip. Resident 1 is a 77 year old Native American female who was admitted to the facility on 3/23/21 with diagnoses that included dementia (mental disease that impairs memory and judgement) without behavioral disturbance, major depressive disorder (extreme sadness and long-term loss of pleasure and interest in life), generalized anxiety disorder, Alzheimer’s (type of dementia that affects memory, language, problem solving and other thinking abilities severe enough to interfere with daily life) disease, feeding difficulties, and generalized muscle weakness. Based on interview and record review, the facility failed to allow Resident 1 to return to the facility following a four-day hospital admission. This failure resulted in an unnecessary extended stay (two additional days) in the hospital and a violation of Resident 1's right to return to the facility. During an interview on 6/4/21, at 3:08 PM, with Administrator, Administrator stated, Resident 1 came to the facility under false pretenses from the family. Administrator stated, the facility admitted Resident 1 on a trial basis to provide extra nourishment. Administrator stated, Resident 1 was at the facility for only a few days, when the facility realized Resident 1 was not suitable for the facility. Administrator stated, the facility had not provided a 30-day notice to the family that Resident 1 was not suitable for the facility. During an interview on 6/4/21, at 4:04 PM, with Hospital Case Manager (HCM), HCM stated, Resident 1 was still at the hospital and Resident 1 was ready for discharge back to her home facility. HCM stated, Resident 1 had been at the skilled nursing facility since 3/23/21 (2 1/2 months) when she fell. HCM stated, the facility informed HCM, the facility did not have enough staff to care for Resident 1. HCM stated, Resident 1 required restraints (devices to prevent the patient from hurting themselves) when she had intravenous (IV – in the vein) medications for a Urinary Tract Infection [UTI]. HCM stated, currently, Resident 1 did not require restraints; Resident 1 does have a sitter (someone to keep close watch on resident to prevent harm). HCM stated, the family was very involved in Resident 1's care. HCM stated, the family lived in town and wanted Resident 1 to return to the facility. During an interview with the Administrator on 6/4/21, at 4:28 PM, Administrator stated, "We [the facility] admitted Resident 1 on 3/23/21. Resident 1 fell [on] 5/28/21 and fractured [her] hip. Now the hospital wants to send her back. We do not have the staff to do [provide] a one-to-one care giver. Resident 1 is restrained in the hospital. Prior to hospitalization, Resident 1's behavior was more redirectable. Resident 1’s daughter informed us Resident 1 was diagnosed with a urinary tract infection [UTI] and required restraints." Administrator was unable to provide documented evidence the facility admitted Resident 1 on a temporary basis. During an interview on 6/4/21, at 5 PM with Ombudsman (patient advocate), Ombudsman stated, the facility had called the family and told them the facility would readmit Resident 1 if the family would pay for a sitter. During a review of the facility's "Admission Record" dated 3/23/21, the Admission Record indicated, Resident 1 was 77 years old, and admitted with the following diagnoses: Alzheimer's disease, anxiety disorder, major depressive disorder, muscle weakness, dementia, unspecified dementia without behavioral disturbance. During a review of the Hospital’s History and Physical (H&P), dated 5/29/21, at 2:40 AM, the H&P indicated, Resident 1 was mildly agitated and upset due to IV access placement, needed for hydration (fluids). During a review of the Hospital Consultation, dated 5/29/21, at 11:03 PM, the Hospital Consultation indicated, Resident 1 did not require surgery for the broken hip. During a review of the Hospital’s Discharge Summary, dated 6/2/21, at 2:08 PM, the Hospital Discharge Summary indicated, the hospital admitted Resident 1 on 5/29/21 for a Right Hip fracture orthopedic (branch of medicine dealing with the musculoskeletal systems) consultation. Resident 1 was evaluated by a physician and there was no recommendation for surgery. “The patient has been doing well and will be discharged to SNF [Skilled Nursing Facility] for further management. The patient will be sent back to her facility for home PT [physical therapy] to be done.” During a review of the Hospitals Final Transition Plan, dated 6/5/21, at 4:20 PM, the Final Transition Plan indicated, the hospital had arranged Resident 1’s transfer to Facility 2 out of town. During an interview on 7/20/21, at 12 PM, with facility 2’s DON (DON 2), DON 2 stated, on 6/5/21, facility 2 admitted and quarantined Resident 1 for 14 days due to COVID-19 precautions. During a review of facility 2’s Admission Record for Resident 1, dated 6/5/21, the Admission Record indicated, on 6/5/21, the facility admitted Resident 1 (three days after the discharge order was written). Facility 2’s Admission record indicated, Resident 1’s diagnoses on admission included: closed fracture with routine healing, unspecified Dementia without behavioral disturbance, unspecified Anxiety disorder, recurrent major Depressive Disorder, generalized muscle weakness, and unsteadiness on feet. During a review of Nutrition and Healthy Aging, the article titled “Hydration Health Literacy in the Elderly,” dated 12/7/17, indicated “The symptoms of dehydration can range from simple dizziness and confusion to seizures and death…the loss of as little as 2-3% of body fluid can cause physical and cognitive impairment.” During a review of the facility policy and procedure titled, “California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities” (The Agreement), dated 5/11, The Agreement indicated, “The California Standard Admission Agreement is an admission contract that this Facility is required by state law and regulation to use. It is a legally binding agreement that defines the rights and obligations of each person (or party) signing the contract…VI. Transfers and Discharges…Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance…VII. 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. You or your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you… If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulation Sections 72520(c) and 73504(c)) to offer you the next available appropriate bed in our Facility. You should also note that, if our Facility participates in Medi-Cal and you are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted.” During a review of the facility Policy and Procedure (P&P) titled, "Bed-Hold and Readmission," dated 10/14, the P&P indicated, "A resident who is transferred to a general acute hospital ...will be afforded a bed-hold of seven (7) days ...This bed-hold policy applies to all residents, regardless of payment source." During a review of the facility P&P titled, "Transfer and Discharge Notice," dated 6/17, the P&P indicated, "The resident and, if known, a family member or resident representative shall be notified in writing and in a language and manner they understand, of the transfer or discharge and the reasons for the move before a transfer or discharge takes place ...The notice must include the following information: a. The reason for transfer or discharge: b. The effective date of transfer or discharge; c. The location to which the resident is transferred or discharged; d. Statements that the resident has the right to appeal the action ...3. The notice of transfer must be made by the facility at least thirty (30) days before the resident is transferred, or as soon as practicable before transfer or discharge when: The safety of individuals in the facility would be endangered ...Documentation must be made in the resident's health record by ...By a physician when: The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. In violation of the above-cited standards, the facility failed to follow their policy and procedures for both “Bed Hold and Readmission” and “Transfer and Discharge” to readmit Resident 1. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constituted a class “B” citation.