Other·April 4, 2024

§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 semiprivate 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. Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 2) reviewed for admission and transfer processes was readmitted to the facility after a hospitalization. This failure had the potential to cause Resident 2 further psychosocial decline by not letting her return to the facility she called home. Findings: Resident 2's clinical record was reviewed. Resident 2 was admitted on 6/9/20 with diagnoses that included suicide attempt, (self-harm to kill themselves), sequela (chronic result or complication of a disease or trauma), suicidal ideations (thoughts of killing yourself with or without a plan), schizoaffective disorder, (a mental health problem with psychosis, loss of reality with mood symptoms), anxiety (feelings of constant worry, tension, and fear), and end stage kidney disease requiring dialysis (a treatment to filter the blood toxins). Review of Resident 2's annual minimum data set (MDS, a resident tool assessment) dated 01/14/24, indicated Resident 2 required extensive assistance with two-person physical assist during activities of daily living such as transfers in and out of bed. Resident 1 had a BIMS (brief interview for mental status) score of 15, indicating Resident 1 was competent to make her own decisions. Review of Resident 2's progress notes dated 01/30/24 at 5:50 pm, indicated "Resident 2 was transferred to acute hospital when a Certified Nursing Assistant (CNA) found resident 2 with a bed remote cord wrapped around Resident 2 ' s neck, and she refused to make a statement." This progress note indicated the resident was transferred on 1/30/24 at 6:05 pm to a local hospital per physician order for an evaluation. A review of Resident 2 ' s discharge notice dated 1/30/24, indicated the facility involuntarily discharged Resident 2 to a local hospital and was necessary for the welfare of Resident 2, and needs cannot be met in the facility. Review of Resident 2 ' s hospital record titled, "History and Physical," (H&P) dated 2/7/24, page five, at 04:25 am, by Registered Nurse (RN) D, indicated, "Resident 2 is in good spirits today and ready to get back to her life. No behavioral issues, no suicidal ideations, and spent time playing on her mobile device talking about her favorite dishes and making jokes with the staff." Review of Resident 2 ' s hospital H&P dated 2/7/24 at, page six, at 7:43 am, by the hospitalist (treating physician while in the local hospital), indicated, "Resident 2 was seen and examined at bedside. No overnight events. Resident 2 does not have any complaint this morning. She is requesting to be discharged. I explained that we are waiting on placement." A review of Resident 2 ' s H&P dated 2/7/24, page 29, at 6:30 pm, by RN E, indicated, "Resident 2 demonstrated no self-harming behaviors today. Resident seems tired but pleasant." During a concurrent record review and interview, on 3/7/24 at 11:30 am, with the Director of Marketing (DOM), an email from a local hospital dated 3/4/24 at 9:04 AM, indicated Case Manager (CM) A wrote, "We were advised that while a Refusal to Readmit appeal is in progress the Skilled Nursing Facility (SNF) is obligated to allow the resident to remain at the SNF. Can you please clarify how this applies to Resident 2? We are concerned her rights are not being honored. Resident 2 continues to remain sitter free since I have included her most recent plan of care below." The DOM confirmed Resident 2's rights were being violated when the facility did not accept Resident 2 back to the facility, and stated, "All I have are copies of emails from CM A from a local hospital and multiple telephone calls trying to get us to take Resident 2 back. I am not allowed to document in the medical records, but I saved the email. I was told by the Administrator (Admin) we could not accept Resident 2 back to the facility and had to relay this information to the CM." DOM confirmed there were no suicide behaviors by Resident 2 on 2/7/24, and stated, "We did not take Resident 2 back due to the Admin's decision, but the hospital said she was stable. I cannot override the Admin." A review of Resident 2 ' s progress note dated 3/5/24 at 6:30 pm, indicated Resident 2 was readmitted to the facility. Licensed Nurse (LN) C wrote, "Resident 2 arrived via stretcher at 5:30 pm to the facility, no distressed noted upon arrival. All needs have been met at this time. Will continue with plan of care." A review of Resident 2 ' s progress note dated 3/5/24 at 11:26 pm, LN C wrote, "Resident 2 ' s mood and behavior is pleasant, no unwanted behaviors witnessed. Resident 2 has no safety concerns, no comfort concerns. Completed clinical suggestions indicated to monitor for anxiety, offer empathy, compassion, support as needed." A review of Resident 2 ' s progress note dated 3/6/24 at 10:26 pm, LN C wrote, "Resident 2 has been calm and cooperative. Resident 2 spent most of the shift socializing with other residents in the hallway and participated in activities. Will continue plan of care." During an interview with the DOM, on 3/7/24 at 10:52 am, the DOM stated, "The local hospital said Resident 2 was stable on 2/7/24, but we felt she was not stable. I do not have the last say, it is the Admin. The Admin said we could not take her back due to her previous behaviors, so that is what I relayed to the hospital." During an interview on 3/7/24 at 11:10 am, the Assistant Director of Nursing stated, "There was no special instructions from the Admin or the Director of Nursing for Resident 2, not to me, and I am the person in charge until tomorrow. I just heard we had to take her back because she won her appeal." During an observation and interview on 3/7/24 at 11:45 am, Resident 2 was resting in bed, no signs or symptoms of restlessness or distress, and stated, "I am ok. I am glad to be back. Today is a good day." During an interview on 3/7/24 at 12:15 pm, LN C stated, "I did the re admission for Resident 2 on 3/5/24. Resident 2 was calm, cooperative, alert, and oriented, and said she was happy to be back." The facility policy and procedure titled, "Readmission," revised 10/1/2013, was reviewed and indicated the purpose of this facility ' s policy is to provide for the readmission of residents who require skilled nursing care at the facility. This facility ' s policy indicated the facility will provide for the readmission of residents who require services provided by the facility and the facility will allow residents who were previously residents of the facility to be readmitted to the facility." The facility failed to allow Resident 2 to return to the facility after a period of hospitalization beginning on 1/30/24. On 2/7/24, Resident 2 filed an appeal of the facility's refusal to readmit. The facility continued to deny readmission, while the appeal was pending, until 3/5/24, 27 days later. This violation occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.