Health inspection·January 7, 2022

F626 Permitting Residents to Return to Facility CFR(s): 483.15 (e)(1)(2) §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. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one of three sampled residents (Resident 1). Resident 1 was transferred to an acute care hospital for evaluation of high temperature on 10/20/2021, and ready to return by 10/26/2021. The facility decided not to readmit Resident 1. On 11/2/2021, the facility told the acute care hospital on their refusal to accept Resident 1. This failure to readmit Resident 1 resulted in Resident 1 emotional stress, was upset and feeling belittled. The facility did not follow their own policy and procedures on Bed Hold, Transfer and Discharge, and Readmission. Findings: Resident 1 was admitted with a diagnosis of hypertensive heart disease with heart failure. Resident 1 was on Medicare and Medicaid. During a telephone interview on 12/2/21 at 10 a.m. with the Complainant, the Complainant stated, Resident 1 had filed an involuntary discharge hearing, and waiting for the result. Resident 1 needed (urinary) indwelling catheter changes often. Resident 1 had urinary infection, a lot of pain and was not treated for at least a week. Resident 1 needed acute care hospital visits often. Resident 1 was transferred to an acute care hospital for treatment on 10/20/2021, and was not re-admitted to the facility as of 12/28/2021. The facility stated no bed, incomparable with Resident 1. Resident 1 was a large size. Resident 1 was very upset and feeling belittled on the facility's refusal for re-admission. Resident 1 specified the desire to return to the facility and happy with the nursing care. Complainant visited the facility and found Resident 1's bed was empty and the personal belongings were still there on 11/2/2021. Complainant stated the facility was possibly in retaliation by not readmitting Resident 1, based on an early complaint (CA00748982 regarding Quality of Care/Treatment. A complaint on the facility for a misread laboratory report and delayed in treatments for urinary infection of Resident 1). Resident 1 was transferred to another facility on 11/11/2021. During an interview on 12/2/21 at 10:50 a.m. with the Administrator Assistant, the Administrator Assistant stated Resident 1 was transferred to an acute care hospital for treatments on 10/20/2021. The Administrator Assistant stated the facility might re-admit Resident 1 if the hearing for involuntary discharge call for re-admission. During an interview on 12/2/2021 at 11 a.m. with the Director of Nurses (DON), DON stated Resident 1 was transferred to an acute care hospital, Emergency Room (ER), on 10/20/2021 and not re-admitted (since 10/26/2021). DON stated there was no written notification of bed hold and refusal for re-admission. DON stated Resident 1 was not re-admitted and the facility had requested the acute care hospital to transfer Resident 1 to another hospital due to need was not able to meet. DON stated before there was a laboratory result (urinary infection), a delay in treatments, and Resident 1 complained. DON stated the facility had no written documentation on the refusal to readmit Resident 1, no written physician's order, no written Care Conference, and no written notification on their refusal to re-admit Resident 1. DON stated there was a hearing for involuntary discharge and waiting for the result. DON had given their reasons for the refusal to re-admit Resident 1 during the hearing. DON stated understanding of the bed hold policy and there was no doctor's order not to re-admit Resident 1. DON stated DON did not refused to re-admit Resident 1. During an interview on 12/20/2021 at 3:50 p.m., with Regulatory Affairs Program Manager, the Regulatory Affairs Program Manager stated the acute care hospital had requested re-admission for Resident 1 by 10/26/2021 and provided documentation. During record review of The State Of California, Department Of Health Care Services, Office Of Administrative Hearings And Appeals. Appeal No.: RTR22-1121-111-ZI, Decision And Order, dated 12/1/2021, indicated, under ISSUE: Whether facility must readmit Resident 1. Under FINDINGS OF FACT: The facility was a long-term health care facility that participates in the Medicare and Medicaid (Medi-Cal) programs. Resident 1 was a Medicare and Medi-Cal beneficiary who was admitted to the Facility on 6/30/2020. On 10/20/2021, Resident 1 moved from the facility, where Resident 1 had been residing, to a hospital for treatment. On 10/26 and 28/2021, Resident 1 requested re-admission to the facility. On 11/1/2021, the facility informed the hospital by phone, that it would not readmit Resident 1. On the refusal to readmit Resident 1, the facility did not provide Resident 1 with a written transfer/discharge notice including the location to which Resident 1 was to be transferred or discharged. It was also established on record that Resident 1 or representative did not receive a written bed-hold notice. On 11/11/2021, Resident 1 was admitted to another facility, where Resident 1 currently resided. On 11/12/2021, Resident 1 filed an appeal of the facility's refusal to readmit. Under REASONS FOR DECISION: 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. Under the law, the refusal of a facility to readmit a resident following a period of hospitalization was treated as an involuntary transfer. The same rights and procedures apply. To conduct a transfer/discharge, a facility must follow designated procedures including providing written notice stating the location to which the resident is to be transferred or discharged. In this case, the facility refused to permit Resident 1 to return to the facility following a period of hospitalization. Therefore, the refusal must be treated as a transfer/discharge and the same rights and procedures apply, including issuing a notice of transfer/discharge. This notice requirement on a refusal to readmit was in addition to any notice requirement that might apply to an initial transfer from a facility to the hospital. For the refusal to readmit, the facility did not provide Resident 1 with a written transfer/discharge notice including the location to which the resident was to be transferred or discharged. Accordingly, the refusal to readmit was improper and the facility must follow a general policy of permitting Resident 1 to return after the period of hospitalization. Facility offered arguments in support of its refusal to readmit Resident 1. None of its arguments constituted a legally recognized exception to the requirement of complying with the discharge/transfer regulation when there was a refusal to readmit. Therefore, the facility's arguments did not change the outcome in this case. Under ORDER: The appeal was granted. The facility should permit Resident 1 to return to the facility. This was the final decision and order of the Department and no further administrative remedies were available. If disagree with this decision, the facility might file a Petition for Writ of Mandate with the Superior Court. During a record review of the acute care hospital Case Manager 1's (CM 1) notes, dated 10/25/2021, indicated CM 1 spoke to the facility's admission coordinator on Resident 1's return by 3 p.m. on 10/26/2021. During a record review of the acute care hospital Case Manager 2's (CM 2) notes, dated 10/28 and 29/2021, CM 2 indicated Resident 1 was medically cleared for discharge on 10/28/2021, and the facility's admission coordinator stated no available bed and Resident 1's bed hold was expired. On 10/29/2021, when CM 2 tried to verify with the facility on when to admit Resident 1, the facility's admission coordinator stated no available beds at the moment and the other answer was no staffing. CM 2 was also advised by the facility's admission coordinator that new admissions were already lined up. During a record review of the acute care hospital Case Manager 3's (CM 3) notes, dated 11/1/2021, CM 3 indicated a message was sent to the facility regarding Resident 1 was ready for discharge today, and the facility's admission coordinator response, "they are not doing admission today." During a record review of the acute care hospital Community Case Manager 1's (CCM 1) notes, dated 11/1/2021, indicated, CCM 1 requested to assist with Resident 1's return to the facility and spoke to the facility's admission coordinator. The facility's admission coordinator stated Resident 1's bedhold had expired and the bed was filled by a new admission, but that he would discuss with clinical team regarding Resident 1. Resident 1 was previously in a private room, which had been given away and currently only three-person room beds available. CCM 1 advised the facility's admission coordinator of Resident 1's right to return to the home facility and requested clarification of the clinical needs that could not be met at their facility, including clinical indication for isolation/private room? The facility's admission coordinator stated would discuss with clinical team. Later in the day of 11/1/2021, the facility's admission coordinator call back and stated, "We cannot accept Resident 1 back because the family member is not satisfied with the care here." CCM 1 indicated an acute care hospital Case Manager had previously documented that both Resident 1 and the family member were in agreement to return to the facility. During a record review of the acute care hospital CCM 1 notes, dated 11/2/2021, indicated, the facility's Director of Nurses (DON) stated Resident 1 and the family had dissatisfaction with the care at the facility, including an incident with inserting a Foley catheter (a urinary tract catheter for urination) that caused Resident 1 a lot of pain and led Resident 1 to question the competency of staff at the facility. DON stated that she was confident in the capabilities of the staff and that Resident 1's clinical needs could be met at the facility. DON stated since Resident 1 and the family member had expressed dissatisfaction with the facility, it would be best for Resident 1 to find alternative placement and therefore the facility was refusing to accept Resident 1's return. During a record review of the acute care hospital Regulatory Affairs Program Manager email to the facility's Chief Executive Officer (CEO), dated 11/4/2021, indicated, Resident 1 had been a resident at the facility for a year until the acute care hospital admission on 10/20/2021. On 10/28/2021, Resident 1's physicians had cleared discharge to the facility and at that time the acute care hospital was informed that the bed hold had expired and there were no beds. On 11/1/2021, the facility's admission coordinator informed the acute care hospital that despite the facility's ability to meet Resident's medical needs, the facility was refusing to take the patient back. On 11/2/2021, CCM 1 spoke with the facility's DON about the refusal and DON informed the acute care hospital that the decision was based upon Resident 1 and the family's dissatisfaction with the care at the facility. The acute care hospital Director of Care Coordination spoke with both Resident 1 and the family member, who stated they were content with the clinical care there and had asked to return to the facility. There was no documented evidence of a response from the facility's CEO. Review of the facility's Admission/Discharge To/From Report for 10/1/2021 to 12/2/2021 indicated a total of 17 discharges [Ten (10) in October, 2021, six (6) in November, 2021, and one (1) in December 1-2, 2021]. [There was an error in the record when it indicated Resident was discharged to an acute care hospital on 10/27/2021 when in fact Resident 1 was discharged to another acute care hospital and the date was since 10/20/2021 but the seven-day bed hold could make the date to become 10/27/2021]. The facility had stated Resident 1's bed was filled by a new admission on 11/1/2021 when the acute care hospital community case manager (CCM 1) requested to assist Resident 1's return to the facility [the acute care hospital Community Case Manager 1's notes, dated 11/1/2021]. Review of the facility's Care Conference Summary, dated 10/9/2021 (latest Resident 1's Care Conference Summary provided by the Administrator Assistant on 12/2/2021), indicated Resident 1 was "alert to person, place, time, and situation. Able to verbalize needs. Incontinent of Bowel and Bladder. Complains of burning pain with urination...No other c/o (complaint of) pain at this time...Lungs are clear...Bowel sounds present...No edema to lower extremities. No SOB (shortness of breath) or respiratory distress. MD (medical doctor) aware of residents return to facility and medication was reviewed...SS (social services) confirmed the resident's upcoming appointments and transportation services. RP (resident representative) made aware of visitation guidelines and the facility's current COVID-19 (a pandemic infection) protocols. Resident continues to participate independent activities in room, ie (that is): reading, watching TV (television), and doing puzzles. Resident receives visits from Activity Staff to offer activities materials of preference". There was no documented evidence to indicate in the Care Conference Summary of not able to care for Resident 1 or short of staffing. During a review of the facility's policy and procedures titled, Bed Hold, revised date was in July, 2017, indicated, the purpose was "To ensure that the resident and the representative is aware of the facility's bed-hold policy, and that such policy complies with state and federal law and regulations." The policy included, "In the event that the resident is in the hospital for more than seven (7) days, meets the standards for skilled nursing care, and is Medi-Cal/Medicaid eligible, the facility will readmit the resident to his/her previous room or the first available bed in a semi-private room." The Procedure included, "Transfer to an acute care hospital/therapeutic leave...The Facility notifies the resident and/or representative, in writing, of the bed hold, option, any time the resident is transferred to an acute care hospital or requests therapeutic leave." There was no documented evidence on meeting the purpose, policy, and procedures of the facility's Bed Hold policy and procedures. The facility failed to meet their own policy and procedures for Bed Hold. During a review of the facility's policy and procedures titled, Transfer and Discharge, revised date was in October, 2017, indicated, the purpose was "To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharg