Other·July 24, 2023

Facility: Del Rosa Villa Janet Murray HFEN 3165 Date of Exit: 6/19/23 Event ID: 5IC511 “B” Citation Del Rosa Villa CA00844081 Representing the department, HFEN 3165 State Citation B Title 22 section 72527 (a) Patients’ Rights (6) To be transferred or discharged only for medical reasons, or the patient’s welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patients’ health record. The facility failed to ensure two discharges had documentation in their health records to indicate the reasons two patients (Patient 1 and 2) were transferred from one skilled nursing facility (SNF, Facility 1) to another SNF (Facility 2), which was not in accordance with Regulations. This failure resulted in an unnecessary transfer for two Patients (Patients 1 and 2) which had the potential for psychosocial harm and possible isolation from family and friends. Findings: On June 6, 2023, at 10:15 a.m., an unannounced onsite visit was conducted at the facility to investigate a complaint regarding Discharge and Transfer Rights for two patients who were transferred to a facility 250 miles away from the facility. 1.During a review of patient 1's clinical record, the face sheet (contains demographic and medical information), indicated Patient 1 was admitted to the facility on February 28, 2022, with diagnoses which included: Metabolic encephalopathy (damage to the brain), schizoaffective disorder (loses touch with reality, hallucinations, delusions), weakness and depression. During review of patient 1's” Interdisciplinary (IDT) Conference Summary” dated October 12, 2022, indicated " ...Patient 1 is currently under Custodial level of care (responsible for providing non-medical care that helps individuals with their activities of daily living [ADLs] such as eating, and bathing also known as long term care) in our facility. Discharge Plan: Needs placement. SSD (Social Services Director) actively searching for placement.... “The IDT Conference summary did not indicate the reason Patient 1 was transferred from one skilled nursing facility (facility 1) to another skilled nursing facility (facility 2). A review of Patient 1’s document titled, "Notice of Proposed Transfer/Discharge" dated June 6, 2022, indicated, "Transfer/Discharge to: (Skilled Nursing Facility.) Note: Regulations require that your transfer/discharge be made for the following reason(s) Check all applicable reasons: 1. The transfer/discharge is necessary for your welfare and your needs cannot be met in the facility. 2. The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by this facility… 3. The safety of individuals in the facility is endangered by your presented. The health of individuals in the facility is endangered by your presence…” The document did not indicate any of the above reasons identified. The facility added a note to the “notice of transfer discharge” that indicated, “…Medically stable. Transferred to long term care facility..." The facility did not indicate the transfer was needed or necessary and made per reasons stated under Regulations as indicated above. The facility transferred Patient 1 to a SNF (facility 2) which provided the same level of care. A review of patient 1's "Discharge Summary" dated June 6, 2022, at 2:13 PM, indicated, " ...Discharge Date and Time ...June 7, 2022, ...Discharge location ...Skilled Nursing ..." A review of patient 1's Physician Order Summary dated June 7, 2022, indicated, "…Why was the Patient discharged: Patients health has improved and no longer requires SNF level of care…Place discharged: Long term care facility.” During an interview and concurrent record review of the Brief Interview Mental status (BIMS) with MDS Nurse (completes assessment data, Licensed Vocational Nurse 1) on June 6, 2023, at 11:47 AM, LVN 1 stated, Patient 1 was discharged on June 7, 2022, to (Facility Name). Patient 1’s BIMS was a 2 on March 3, 2022. LVN 1 stated, “A two signifies, they are not able to answer all of the questions. It is a low number…On June 3, 2022, it got a little better. It was a four. I would say he does not have decision making capacity.” BIMS score of zero through seven signifies severe cognitive impairment. During an interview with Social Services (SS1) on June 6, 2023, at 12:47 PM, SS1 stated, “Discharge note: Patient 1 to discharge to long term skilled facility. Nurses to be available during transport. That’s the newest note. Patient 1 was here for a while. Patient 1 did not request to transfer to another facility. Not in the notes. It is a facility initiated transfer.” SS1 stated further the medical records did not indicate a reason for patient 1’s transfer. During a review of the clinical record for patient 1, the medical records did not state any valid reason for transferring patient 1 to another skilled nursing facility. 2.During a review of patient 2's clinical record, the face sheet (contains demographic and medical information), indicated Patient 2 was admitted to the facility on February 18, 2022, with diagnoses which included, stroke affecting the right side, aphasia (trouble speaking), encephalopathy (damage to the brain), and depression. During a review of patient 2's” Interdisciplinary (IDT) Conference Summary” dated October 12, 2022, indicated "...Patient 1 is currently under Custodial level of care (responsible for providing non-medical care that helps individuals with their activities of daily living [ADLs] such as eating, and bathing also known as long term care) in our facility. Discharge Plan: Needs placement. SSD (Social Services Director) actively searching for placement.... “The IDT Conference summary did not indicate the reasons Patient 2 was transferred from one skilled nursing facility (facility 1) to another skilled nursing facility (facility 2). A review of Patient 2’s document titled, "Notice of Proposed Transfer/Discharge" dated June 6, 2022, indicated, "Transfer/Discharge to: (Skilled Nursing Facility.) Note: Regulations require that your transfer/discharge be made for the following reason(s) Check all applicable reasons): 1. The transfer/discharge is necessary for your welfare and your needs cannot be met in the facility. 2. The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by this facility… 3. The safety of individuals in the facility is endangered by your presented. The health of individuals in the facility is endangered by your presence…” The document did not indicate any of the above reasons identified. The facility added a note to the “notice of transfer discharge” that stated, “…Medically stable. Transferred to long term care facility..." The facility did not indicate the transfer was needed or necessary and made per reasons stated under Regulations as indicated above. The facility transferred Patient 2 to a SNF (facility 2) which provided the same level of care. A review of patient 2's "Discharge Summary" dated June 6, 2022, at 2:09 PM, indicated, " ...Discharge Date and Time ...June 7, 2022, ...Discharge location ...Skilled Nursing ..." A review of patient 2's Physician Order Summary dated June 7, 2022, indicated, "…Why was the patient discharged: Patients health has improved and no longer requires SNF level of care…Place discharged: Long term care facility.” During an interview and record review of the Brief Interview of Mental Status (BIMS) with MDS Nurse (completes assessment data, Licensed Vocational Nurse 1) on June 6, 2023, at 11:47 AM, LVN 1 stated, “Patient 2 was discharged on June 7, 2022, to (skilled nursing facility). Patient 2’s BIMS status was a 2 on January 17, 2022…LVN 1 stated, On June 7, 2022, it was a 4. Patient 2 had other cognitive issues from the stroke. He went to (Facility 2) too. I always thought that was far away. That’s another facility. They are a sister facility.” BIMS score of zero to seven signifies severe cognitive impairment. During an interview with Social Services (SS1) on June 6, 2023, at 12:47 PM, SS1 stated, “Patient 2 did not request to be transferred. This is a facility initiated transfer. Patient 2’s records don’t say why he was transferred.” During an interview with the Director of Nursing (DON) on June 6, 2023, at 1:50 PM, the DON reviewed the medical records for Patient1, and Patient 2 then stated the notes did not state that Patient 1 and Patient 2 requested the transfer to another skilled facility. It is a facility initiated discharge. The DON was asked why Patient 1 and Patient 2 were transferred to another skilled nursing facility. The DON stated, “I don’t have that information for you.” The DON was unable to provide documentation that stated the reasons Patient 1 and Patient 2 were transferred to another skilled nursing facility (facility 2) which was their sister facility. During a concurrent review of the policy and procedure (P&P) titled “Transfer or Discharge…” with the DON. The P&P indicated, “Patients will not be transferred unless: a. The transfer or discharge is necessary for the patient’s welfare and the patient’s needs cannot be met at the facility, b. The transfer or discharge is appropriate because the patient’s health has improved sufficiently so the patient no longer needs the services provided by the facility…” The DON stated they did not follow their policy and procedure for Transfer and Discharge. When the DON was asked why it is important to follow their “Transfer or Discharge…” Policy and Procedure the DON stated, “It is for the welfare of the patient. To make sure we serve the patient and be their advocate.” During an interview and concurrent review of the facility’s” Transfer or Discharge...” Policy and Procedure regarding discharges and transfers with the Administrator on June 6, 2023, at 1:55 PM, the Administrator stated, “We did not follow our policy and procedure” when Patient 1 and Patient 2 were transferred to another skilled nursing facility (their sister facility, facility 2) and received the same level of care 250 miles away. During a review of the facility’s Policy and Procedure titled, “Transfer or Discharge…” dated August 2018, indicated” …1. Patients will not be transferred unless: a. The transfer or discharge is necessary for the patient’s welfare and the patient’s needs cannot be met at the facility, b. The transfer or discharge is appropriate because the patient’ health has improved sufficiently so the patient no longer needs the services provided by the facility…” During a review of the facility’s policy and Procedure titled, “Discharge” dated December 2015, indicated” …Notice of Proposed Transfer/Discharge 1. A transfer or discharge will be in accordance with federal and state law or upon the request of patient/family. A. Federal Regulations specify the following: i. A thirty (30) day notification of discharge before the discharge occurs in the following cases: 1. The patient’s welfare and needs cannot be met in the facility. 2. The patient has failed, after reasonable and appropriate notice, to pay a day at the facility. 3. The facility ceases to operate. ii Notification as soon as practicable in the following cases: 1. The safety of individuals in the facility would be endangered. 2. The health of individuals in the facility would be endangered. 3. The patient’s health has improved sufficiently to allow a more immediate transfer or discharge. 4. An immediate transfer or discharge. 4. An immediate transfer or discharge is required by the patient’s urgent medical needs, or discharge. 5. A patient has not resided in the facility for thirty days…5. Written notification will be in accordance with federal and state law. Conclusion: The facility failure to discharge patients for medical reasons, or for the patient’s welfare or for nonpayment of stay placed patients 1 and 2 at risk for psychosocial harm when the patients were transferred without documentation that indicated the reason or the need for the transfer to another skilled nursing facility. The violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety or security of patients or Patients.