Health inspection·June 20, 2023

Waterman Canyon CA00841624 The following reflects the findings of the California Department of Public Health During the investigation Representing the department, HFEN: 44909 State Citation B (HSC section 1439.6 SECTION 1. Section 1439.6 is added to the Health and Safety Code, to read) 1439.6 (1) (a) Except as provided in subdivision (b), if a resident is notified in writing of a facility-initiated transfer or discharge from a long-term health care facility, the facility shall also send a copy of the notice to the local long term care ombudsman at the same time notice is provided to the resident or the resident’s representative. (b) If a resident is subject to a facility-initiated transfer to a general acute care hospital on an emergency basis, the facility shall provide a copy of the notice to the ombudsman as soon as practicable. (c) The copy of the notice shall be sent by fax machine or email, as may be directed by the local long-term care ombudsman, unless the facility does not have fax or email capability, in which case the copy of the notice shall be sent by first-class mail, postage prepaid. A facility’s failure to timely send a copy of the notice shall constitute a class B violation, as defined in subdivision (e) of Section 1424. (d) For the purposes of this section, a “facility-initiated transfer or discharge” is a transfer or discharge that is initiated by the facility and not by the resident, whether the resident agrees to the facility’s decision. The facility failed to ensure the Ombudsman was notified of facility-initiated transfers or discharges in May 2023, for three of three Patients (Patients 1,2 and 3), when Patients 1, 2 and 3 were transferred to [A sister facility 5 hours away]. This failure resulted in three Patients (Patients 1, 2 and 3) not receive the added protection the Ombudsman provides by ensuring these patients did not leave the facility without access to an advocate who could confirm the patients’ rights for a safe discharge. This failure to follow the facility approved Policy and Procedure (P&P) resulted in the ombudsman not being able to monitor and if needed, advocate for the patients’ rights to a safe and appropriate transfer. This placed them at risk of isolation from family and friends. On May 23, 2023, at 10: 20 AM, an unannounced visit was conducted at the facility to investigate a complaint regarding a transfer and discharge of three patients without notification to the Ombudsman. 1.During review of Patient 1’s Admission Record (general demographics), the document indicated Patient 1 was admitted to the facility July 19, 2022, with diagnosis to include seizures (burst of uncontrolled twitching/convulsions), major depressive disorder (depressed mood), and anxiety disorder. During a review of Patient 1’s “Progress Note” dated May 10, 2023, at 11:44 AM, the document written by Social Service indicated, “I met with Patient per her request to inform us that she would like to be discharged to [Sister facility 5 hours away] after giving her updates and choices for her to continue care of plan back to community. So, Patient requested to do all arrangements necessary to transfer to [Sister facility].” During review of Patient 1’s “Progress Note” dated May 10, 2023, at 3:30 PM, the document written by Social Services, indicated “Social services met with Patient, per Patient request she would like to be transferred to [Sister facility 5 hours away] on May 12. 2023. Patient seemed excited about the transfer. Patient made aware Doctor okay with move”. During review of Patient 1’s “Progress Notes” dated May 11, 2023, at 8:32 AM, the document written by a License Vocational Nurse 1 (LVN), indicated, “Per Patient’s request, may be discharged to [Sister facility 5 hours away] on Thursday May 12, 2023. MD (doctor) and RP (Patient representative) made aware. Order noted and carried out” During review of Patient 1’s “Progress Notes” dated May 11, 2023, at 9:24 AM, the document written by LVN 2, indicated, “IDT (inter disciplinary team a group of clinical staff- nursing, activities, dietary, and social services) met to discuss plan of care for the Patient due to close contact with an individual who tested positive for Covid-19 today May 8, 2023, and on May 11, 2023 During review of Patient 1’s “Progress Notes” dated May 11, 2023, at 9:47 PM, the document written by LVN 3, indicated “Patient on isolation with droplet precautions related to individual with Covid 19, may cohort (a group of people with shared characteristics) one time only for 7 days. Start date: May 11, 2023, End Date: May 5, 2023, orders noted and carried out. MD and RP notified”. 2. During review of Patient 2’s “Admission Record (general demographics), the document indicated Patient 2 was admitted to the facility on June 23, 2022, with diagnosis to include unsheltered homelessness, alcohol abuse (excessive alcohol use), major depressive disorder (depressed mood), suicidal ideations (suicidal thoughts). During review of Patient 2’s “Progress Notes” dated March 27, 2023, at 12:24 PM, the document written by LVN 3, indicated, “IDT (inter disciplinary team) met to discuss plan of care for the Patient due to close contact with an individual who tested positive for Covid-19 today, March 10,2023, there were 2 Covid 19 positive cases on March 13, 2023”. During review of Patient 2’s “Progress Notes” dated March 29, 2023, at 7:14 AM, the document written by SSD (social services department), indicated, “SSD met with Patient, and he stated, ‘What happened to me transferring to another facility?’ SSD explained to Patient it was a process finding an accepting facility. SSD mentioned to Patient [Sister facility 5 hours away] has a bed available, Patient response as, ‘That’s where I thought I was going.’ SSD will follow up with admission to [sister facility] for transfer. SSD refaxed information to [sister facility] per Patient’s request”. During record review of Patient 2’s “Progress Notes” dated March 30, 2023, at 1:33 PM, the document written by LVN 1, indicated, “Per Patient’s request, may transfer to [sister facility] MD and RP made aware. Order noted and carried out.” During record review of Patient 2’s “Progress Notes” dated March 30, 2023, at 2:06 PM, the document written by SSD, indicated “SSD met with Patient to inform him he will be transferring tomorrow to [A sister facility 5 hours away] and transportation will be here at around 8:30 am.” During record review of Patient 2’s “Progress Notes” dated on March 30, 2023, at 6:41 PM, the document by Registered Nurse 1 (RN), it indicated, “Patient on isolation with droplet precautions R/T (related to) re-exposure with Covid 19. May cohort every shift for 7 days. One time only for 7 days. Start date: March 27, 2023, End date: April 2, 2023, orders noted and carried out. MD and RP notified.” During record review of Patient 2’s “Progress Notes” dated March 31, 2023, at 8:24 AM, the document written by LVN 4, indicated, “Patient discharged via van accompanied by attendee. All current medications given to Patient /attendee at the time of leave. Patient was in good spirits. Patient able to verbalize and understand the process of discharge. Explained and educated Patient /attendee regarding medication administration.” 3.During review of Patient 3’s “Admission Record” (general demographics), the document indicated Patient 3 was admitted to the facility on January 22, 2023, with diagnosis to include heart failure (severe failure of the heart to function properly) muscle weakness, acquired absence of left leg below knee, metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood). During record review of Patient 3’s “Progress Notes” dated May 10, 2023, at 3:31 PM, the document written by SSD, indicated “I met with Patient per Patient request he would like to plan to be transferred to [sister facility] on May 12,2023. Patient seemed excited about transfer. Patient made aware Doctor okay with move.” During record review of Patient 3’s “Progress Notes” dated May 11, 2023, at 8:31 AM, the document written by LVN 1, indicated, “Per Patient s request, may be discharged to [Name of sister facility 5 hours away] Thursday May 12, 2023. MD and RP (responsible party) made aware. Order noted and carried out.” During an interview with Interview Discharge Coordinator on May 23, 2023, at 1:10 PM, she stated, “Patients get discharged according to their insurance.” The Discharge Coordinator stated, “For example, if a Patient has insurance, the insurance gets an update on the Patient’s progress, and they ultimately make the decision to transfer the Patient based on their ability to care for themselves and their progress in their health. That was the case with [Names of Patients 1, 2 and 3. The Patients were presented with the option of being transferred and they all agreed.” During an interview on May 24, 2023, at 3:07 PM, with the Administrator of the sister facility where Patient 1, 2 and 3 had been transferred to, he stated “I went to [Name of sister facility that transferred Patients]to talk to these Patient on April 25, 2023, and April 26, 2023, regarding plans for transfer. It was clearly explained, and the Patients agreed”. During a review of the facility’s policy and procedure titled, “Transfer and Discharge Notice “revised April 2022, the Policy and procedure indicated “In determining the transfer location for a Patient, the decision to transfer to a particular location will be determined by the needs, choices and best interest of that Patient.” During a review of the facility’s policy and procedure titled, “Transfers/Discharges” revised December 2016, the policy and procedure indicated, “Our facility shall provide a Patient and/or the Patient’s representative (sponsor) with a (30)-day written notice of an impending transfer or discharge….4. A copy of the notice will be sent to the Office of the State Long-term Care Ombudsman. At the request of the State Long-Term care Ombudsman, the notice will be sent once a month”. Conclusion: The facility failure to notify the Ombudsman of facility-initiated discharges and transfers placed patient 1,2 and 3 at risk for unsafe discharges. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or Patients.