Health inspection·July 19, 2024

Mountainview Health Care Center 055316 CA00905551 Event ID: 42VS11 Complaint # CA00905551 Scope and Severity: H F622 Transfer and Discharge Requirements §483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §483.15(c)(2) Documentation. Based on interview and record review, the facility (Facility A) failed to permit five of 21 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) to remain at the facility and not transfer to another facility without appropriate reason/s for discharge when: 1. Resident 1 was transferred to Facility B by a facility-initiated discharge (a transfer or discharge which the resident objects to or did not originate through a resident's verbal or written request) without an appropriate reason for discharge in accordance with CFR 483.15(c)(regulation with specific criteria for discharge/transfer of residents). 2. Resident 2 was transferred to Facility B by a facility- initiated discharge without an appropriate reason for discharge in accordance with CFR 483.15(c). 3. Resident 3 was transferred to Facility C without documented evidence indicating Resident 3 requested the discharge. 4. Resident 4 was transferred to Facility B without documented evidence indicating Resident 4's responsible party (health care decision maker) requested the discharge. 5. Resident 5 was transferred to Facility B by a facility-initiated discharge without an appropriate reason for discharge in accordance with CFR 483.15(c). These failures contributed to: a. Psychosocial harm to Resident 1 evidenced by, difficulty with transition to new facility (Facility B), difficulty of friends to visit new facility due to farther distance, and Resident 1 expressing a repetitive sadness and depressed mood from lack of visitors. b. A potential for psychosocial harm (depressed mood, or decreased engagement in activities) to Resident 2 and Resident 3, when their environments changed without a timely notice of discharge, and opportunity to refuse the transfer/discharge. c. A potential for psychosocial harm (depressed mood, or decreased engagement in activities) to Resident 4 using the reasonable person standard as evidenced by family being unable to visit as frequently as before the transfer due to facility being further away from Resident 4's responsible party's residence. Resident 4 had the potential to experience depression and or loneliness. d. A potential for psychosocial harm (depressed mood, or decreased engagement in activities) to Resident 5 using the reasonable person standard as evidenced by friend being unable to visit facility since transfer due to facility being farther away. Resident 5 has potential to experience depression and or loneliness. Findings: 1. During a review of Resident 1' Facesheet (demographic document, typically include the patient's name, address, date of birth, insurance information, and emergency contact information), undated, it indicated, Resident 1 was admitted to Facility A on 4/27/24, and Resident 1 was her own responsible party. Review of Resident 1's "Social Service Assessment" for admission dated 4/27/24, completed by social services director (SSD), the assessment indicated, Option 2 was selected for long term stay " Discharge Planning Anticipated Length of Stay as: 2) Long Term. . . SW met with [Resident 1] and friend as POA [Power of attorney-a legal document that allows someone else to act on your behalf] at bedside. . .No behavior issues or mental health." Review of Resident 1's "Notice of Proposed Transfer or Discharge" dated 6/11/24 by SSD, the Notice indicated, the discharge type was selected as facility initiated, and the resident did not require care at facility. "1. Transfer or Discharge Type 2. Facility Initiated Transfer. . .4. Date of Transfer/Discharge 6/11/2024. . .Reason for Discharge in accordance with CFR 483.15 (c) (F622) 1. Resident's health has improved sufficiently that the resident no longer needs the services provided by the facility. . .Transfer or Discharge Address [Facility B Address- Another Skilled Nursing Facility]". During an interview on 6/25/24, at 10:36 a.m., with the SSD, the SSD stated, "I selected the option in the discharge reason for Resident 1, that the residents health improved because no other option applied to her". The SSD confirmed Resident 1 would be receiving the same care at the other facility (Facility B) where she was transferred/or discharged to and still needed long term care. During an interview on 6/20/24, at 2:15 p.m., with Friend A (FA), FA stated, they are friends with Resident 1 for over 40 years now. FA stated, the SSD told her they needed to move Resident 1 to their sister facility (Facility B) because "they needed her bed for other prospective patients. I think they [facility] got exasperated with [Resident 1] because she is not an easy person to deal with, they did not offer her long-term stay". FA also stated, "[Resident 1] didn't want to leave, she wasn't happy about it." FA stated, "they [facility A] told us they needed the bed space for other patients. FA stated, she had not visited Resident 1 at Facility B because its too far away, previously she would visit several times a week when Resident 1 was still in Facility A. During an interview on 6/20/24, at 4:30 p.m., with Friend B (FB), FB stated, he had been friends with Resident 1 for over 40 years. FB stated, the SSD told him, Resident 1 was transferred to another facility because they "were running out of room and they needed the bed". FB stated, the SSD was the one who told this to him. FB stated, there is no way Resident 1 would have requested to go, she is "so demented, she sees objects that are not there in the room". FB hasn't been able to visit Resident 1 because the new place (Facility B) was too far away. During an interview on 6/21/24, at 9:15 a.m., with Friend J (FJ), FJ stated, she had the POA for Resident 1, and neither her nor Resident 1 requested the transfer. FJ stated, the SSD told us they are just "holding" Resident 1 at the facility (Facility A) until there is space at Facility B. FJ stated, the SSD told her they are transferring her to Facility B because it is "more of a long-term care" place, and she can get physical therapy there. FJ stated, "when I visited her (Resident 1) first week at [Facility B], she had a horrible week, she was confused, she seemed depressed, the facility had to call me almost every day to get her to take her medications, Resident 1 was so upset she had to move". FJ stated, (Resident 1) kept asking her "Why did they make me leave the other place". During an interview on 6/24/24, at 1:17 p.m., with Physician D (PD), PD stated, he was Resident 1's Primary Physician in both Facility A & Facility B. PD stated, Resident 1 still required long term care, she is getting the same level of care at [Facility B]. PD also stated, he was not sure why Resident 1 was transferred, the only reason to transfer to another skilled nursing facility was if the family or the resident requested to be transferred. Review of Resident 1's "Admission Agreement", dated 3/12/24, it indicated,.. "VI. Transfers and Discharges. . . The only reason we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being, because your needs cannot be met in our Facility;2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate. 6) Material or fraudulent misrepresentation of your finances to us." No documented evidence reasons (1-6) were applicable to Resident 1's reason for transfer were found. During an interview on 6/26/24, at 11:22 a.m., with Resident 1 in her room at Facility B, Resident 1 stated, she was not sure why she was transferred to Facility B. Resident 1 stated, her other friends were not able to visit her yet because of the distance and it made her feel depressed. 2. During a review of Resident 2's Facesheet dated 6/19/24, the Facesheet indicated, Resident 2 was admitted to Facility A on 3/3/24, and was her own responsible party. During a review of Resident 2's Admission Social Service Assessment completed by the SSD on 4/9/24, it indicated, "Anticipated length of stay 2) Long term Care". During a review of Resident 2's "Notice of Proposed Transfer or Discharge", completed by the SSD on 6/11/24, Notice indicated, Resident 2 was transferred by the facility because she no longer needed services, "Transfer or Discharge Type: 1.Facility initiated Discharge. . .Date of discharge 6/11/24. . . 5. Transfer or Discharge Address [Facility B address-another skilled nursing facility]. . . Reason for Discharge in accordance with CFR 483.15 (c) 1. Resident's health has improved sufficiently that the resident no longer needs the services provided by this facility." During an interview on 6/20/24, at 3:46p.m., with Physician C (PC) PC stated, she was Resident 2's Primary Physician while at Facility A. PC stated, they did not initiate the transfer to another facility for Resident 2. PC stated, the facility notified PC the Resident is being transferred. PC stated I assume either the Resident or the family requested the transfer, that is usually the only reasons for transfer to another skilled nursing facility. During an interview on 6/25/24, at 10:36 a.m., with the SSD, the ]SSD stated, "I selected the option in the discharge reason for [Resident 2], that the residents health improved because no other option applied to her", the SSD stated Resident 2 is receiving the same level of care at Facility B. During a review of Resident 2's "Admission Agreement", dated 3/3/24, it indicated, "VI. Transfers and Discharges. . . The only reason we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being, because your needs cannot be met in our Facility;2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate. 6) Material or fraudulent misrepresentation of your finances to us." No documented evidence reasons (1-6) were applicable to Resident 1's reason for transfer were found During an interview on 6/26/24, at 11:20 a.m., with Resident 2, Resident 2 did not respond to any questions, she stared blankly straight ahead without eye contact. During a review of Resident 2's BIMS (Brief Interview for Mental Status-an assessment tool used to identify cognitive status) score dated 6/11/24, indicated a score of 9, indicating moderate cognitive impairment. 3. During a review of Resident 3's Facesheet indicated, Resident 3 was admitted to Facility A on 5/23/24 and her own responsible party. During a review of Resident 3's Admission Social Service Assessment dated 5/25/24, it indicated, "DC plan either return to B&C [board and care-a licensed residential home that provides non-medical care] or long term care". During a review of Resident 3's "Notice of Proposed Transfer or Discharge" completed by Social Services E (SS E) dated 6/15/24, it indicated, Resident 3 requested a transfer, and no longer needs services, "1. Transfer or Discharge Type 4. Resident/Resident Representative requested transfer. . . Date of Transfer/Discharge 6/16/24. . .6. Reason for Discharge in accordance with CFR 483.15(c)(F622) 1. The Resident's health has improved sufficiently that the resident no longer needs the services provided by the facility." During an interview on 6/20/24, at 4:30 p.m., with SS E, SS E stated, "I think Resident 3's daughter requested Resident 3 to be transferred to [Facility C] to be closer to her." During an Interview on 6/21/24, at 10:16 a.m., with the Assistant Administrator (AA), Surveyor requested documentation indicating Resident 3 had requested for the transfer. The AA stated Resident 3 had a progress note that indicated Family L (FL) requested the transfer. During a review of Resident 3's Progress note dated 6/14/24, it indicated, "[FL] would like referral to go to [Facility C] and if not accepted is agreeable to dc [discharge to] [Facility B], only if resident agreeable". No documentation was available to support Resident 3 agreed or requested to transfer to another facility being her own self-responsible for decision making. During an interview on 6/20/24, at 1:15 p.m., with FL, FL stated, "I don't know why [Resident 3] was transferred, you'd have to ask her" FL stated, she didn't request anything. During an interview on 6/24/24, at 1:17 p.m., with PD, PD stated, he was the Primary Physician for Resident 3 at former facility. PD stated, he assumed Resident 3 was transferred to be closer to family, since she went to Facility C . PD stated, "It is primarily the Social Workers who are involved with transfers, so they would know the reason." During an interview on 6/26/24, at 9:10 a.m., with Resident 3 at Facility C, Resident 3 stated, The reason they transferred me to Facility C was "They [Facility A] told me they didn't have a bed for me to stay. I asked them what about the bed I'm in now? They said they didn't have any long term beds available". "I don't remember who spoke with me, but they did not give me the option to stay." Resident 3 stated, "I would have loved to stay there [Facility A] for long term, they told me they wouldn't have accepted me if I was going to stay long term". Resident 3 stated, she had to either transfer to Facility B or Facility C. Resident 3 stated, "I'm more sad". "I wish I could have stayed and not moved". Resident 3 stated, she is still receiving the same level care, and is continuing physical therapy. During a review of Resident 3's "Admission Agreement", dated 5/23/24, Agreement indicated, "VI. Transfers and Discharges. . . The only reason we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being, because your needs cannot be met in our Facility;2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endan