Health inspection·May 24, 2024

California Code of Regulation Title 22, Division 5, Chapter 3, Article 5 72523 Patient Care Policies and Procedure (a) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Code of Federal Regulation Title 42, 483.15 (c) (7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. It was determined that the facility failed to arrange a safe and orderly discharge for Patient 2, when the facility arranged for the patient to be transported to a Board and Care 2 (B & C - a care provider with a lower-level care compared to a Skilled Nursing Facility [or Nursing Home]), without appropriate arrangement with Patient 2, Patient 2's family, and the receiving facility. This failure of the facility resulted in Patient 2 being left outside B & C 2, alone, unsupervised, and without certainty of being admitted to the board and care. Patient 2 was transferred to the general acute care hospital (GACH), due to B & C 2 being unaware of where the patient came from and behavior issues. In addition, this failure of the facility to ensure safe and orderly discharge is a substantial factor that can cause direct psychological harm to Patient 2. On March 27, 2024, at 10:43 a.m., an unannounced visit to the facility was conducted to investigate a transfer and discharge issue. A review of Patient 2's medical records indicated an admission to the facility on December 16, 2023, with diagnoses of left shoulder osteoarthritis (a progressive disorder of the joints caused by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the joints), dehydration (a harmful loss of the amount of water in the body), colitis (a chronic inflammation of the inner lining of the colon), legal blindness, and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 2's Minimum Data Set (MDS- an assessment tool), Section C: Cognitive Patterns, dated December 19, 2023, indicated Patient 2 has a Brief Interview for Mental Status (BIMS- tool used to assess cognitive status of elderly patients) score of 06. The MDS manual indicated a BIMS score of 06, meant severe impairment in cognition. On March 27, 2024, at 2:17 p.m., an interview was conducted with the Skilled Nursing Facility (SNF) Social Service Director (SSD), and she stated the following: > Patient 2 was discharged to B & C 1 on March 25, 2024. > On March 25, 2024, she received a call from the transporter, informing her that B & C 1 refused to accept the patient because he was male. >The SSD called other B & C facilities in the area to find placement for Patient 2. > The SSD spoke with an "employee" at B & C 2, and the facility agreed to admit Patient 2. She emailed Patient 2's medical records to B & C 2 and provided the new address to the transporter. > On March 26, 2024, she received a call from a GACH social worker (SW), reporting that Patient 2 was at their hospital. The SNF SSD stated that she was informed by the GACH SW that the patient was found outside B & C 2, and that the board and care staff called 911. > They should have taken the patient back to the facility instead of finding another board and care. The SNF SSD stated that Patient 2's family member and the Ombudsman were not notified of the new location (B & C 2). On March 27, 2024, at 4:48 p.m., an interview was conducted with the facility administrator (ADMIN). The ADMIN stated that he was aware of Patient 2's discharge. The ADMIN stated that Patient 2's discharge was not the normal protocol that they follow. On March 28, 2024, at 8:37 a.m., a telephone interview was conducted with the GACH SW (the GACH SW who called the SNF SW on 3/26/2024). The GACH SW stated Patient 2 was transferred into the emergency room on March 25, 2024. The GACH SW stated that the hospital staff had to call Patient 2's family member to find out where the patient came from prior to being found outside B & C 2, since they did not know what facility the patient came from prior to coming to B & C 2. On May 22, 2024, at 2:44 p.m., a telephone interview was conducted with the owner of B & C 1, the owner stated Patient 2 was accepted for placement approximately two weeks prior to the date of March 25, 2024. The owner stated that they usually would receive a call from the facility regarding the estimated time of arrival; however, the owner stated they did not receive a phone call from the skilled nursing facility to confirm of the patient's transfer to their board and care (B & C 1). The owner stated a private room was reserved for Patient 2 and they were willing to take the patient on March 25, 2024, and they did not deny Patient 2's admission due to the patient being male. The owner disclosed that B & C 1 caregiver (CG) reported that the day of March 25, 2024, Patient 2 was very agitated, trying to get off the gurney, and that the transport staff left the board and care (B & C 1) with the patient. On May 22, 2024, at 3:14 p.m., a telephone interview was conducted with Patient 2’s Representative (Rep). The Rep stated Patient 2 was not able to make decisions and had difficult behaviors. The Rep stated that it was his understanding that the facility only provided short term care and had not been provided the option to stay at the facility long-term. The Rep stated that the SNF (SNF 1) had not called him to inform him of the transfer to B & C 2. The Rep stated it was the hospital’s SW who had contacted him to inform him of Patient 2’s location, being at the GACH. The Rep stated that he was not offered an option to return to the facility and he was not involved in the decision to transfer the patient to another skilled nursing facility (SNF 2). Patient 2's Rep stated he preferred for the patient to stay at SNF 1. On May 22, 2024, at 3:42 p.m., a telephone interview was conducted with the CG at B & C 1. The CG stated that on March 25, 2024, a van arrived with Patient 2. The CG stated that they had not received a call from the facility and the driver had taken Patient 2 out of the van and wheeled him on to the driveway. The CG stated Patient 2 was agitated and tried to get off the gurney. The CG stated that the driver was unsure if he was at the right location and made three to four phone calls. The CG stated the driver received a phone call, and stated he was at the wrong location, and loaded Patient 2 back into the van and left. A review of Patient 2's "Discharge Summary," dated March 21, 2024, indicated "...DC plan for 3/25/24 accepted at (Name of B & C 1) board and care (name) transport ... (Name) home health ...PT (Physical therapy)/ OT (occupational therapy)/RN (registered nurse) ...DME (durable medical equipment) hospital bed..." A review of Patient 2's "72-hour Charting, " dated March 25, 2024, indicated, "patient discharged ...via gurney with the help of two (Name of transport company) transport attendants on 3/25/24 at 10:46 ... patient meds and belongings sent with transportation and patient...treatment as noted: Lesion to right (R) ear: Cleanse w/(with) NS, pat dry. Swab w/ Betadine and may leave open to air daily x 14 days, then re-eval. (Family member' s name) ...and medical doctor (MD) notified." A review of Patient 2's "Social Service Note," dated March 25, 2024, at 12:35 p.m., indicated "Late Entry: received a call from transportation and they expressed that board and care would not accept pt (patient) due to he was a male ...ssd (sic) called board and cares (sic) around the area and (Name of person) from (Name of B & C 2) board and care agreed for pt to admit...ssd (sic) gave new address to transport..." A review of Patient 2's "Social Service Note, " dated March 26, 2024, at 12:39 p.m., indicated, "received a call from (Name of GACH). per (sic) social worker, pt (patient) was admitted to the er (Emergency Room) yesterday. Per social worker (at the hospital), pt showed up on their (board and care)'s (B & C 2) doorstep and the facility had no idea that pt would be admitted..." On May 24, 2024, at 9:44 a.m., in an interview with the owner of B & C 1, the owner stated she acknowledged accepting Patient 2 a couple of weeks prior to the date of March 25, 2024, and someone from the facility also called a week prior that the patient is coming. However, she stated she did not get a call from the facility to confirm the patient's admission to her board and care, so she was unable to inform the caregiver of the board and care where Patient 2 was supposed to be going. She stated she owned several B & C homes, which created some confusion because the transport arrived at one of her B & C homes (not B &C 1, with a different address) that had no vacancy. Subsequently, the transportation brought over the resident to B & C 1. The CG at B & C 1 was not aware of any admission since she (owner) was not made aware that the patient was in fact coming that day (March 25, 2024). On May 24, 2024, at 10:21 a.m., in an interview with the House Manager of B & C 2, she stated that on March 25, 2024, she found Patient 2 sitting by the steps of the boarding care upon opening the door to check if someone placed a medication by their mailbox. She stated Patient 2 was with a blanket, a bag, and a coffee cup. The HM stated the patient was alone, and when asked to get up stated he could not see clearly and could not walk. The HM stated she called 911 because she does not know Patient 2 and she did not know where the patient came from. The HM stated she was always made aware by the B & C if a new admission was coming. The HM confirmed there was no planned admission that day (March 25, 2024). On May 24, 2024, at 1:16 p.m., in a concurrent interview and record review with the Case Manager/Discharge planner, she stated the progress notes and the discharge summary for Patient 2, indicated the name of the board and care (B & C 1), but she could not find any notes indicating an address of the board and care. She stated that sometimes, the SW would directly let the transport person know the address. She verified that she could not find any documentation indicating whether the SNF SW called the board and care (referring to B & C 1) the day of the discharge to ascertain why the patient was not accepted in the board and care (B & C 1) as arranged. A review of the GACH 's medical records indicated the following: a. On March 25, 2024, at 5:14 p.m., "...history of dementia presents from boarding care for placement. Per EMS (Emergency Medical Services-system that responds to emergencies in need of highly skilled pre-hospital clinicians), they are unable to care for him due to dementia and behavior issues..." b. On March 25, 2024, at 9:03 p.m., "...MSW (Master of Social Work) attempted to complete a consult asking for assistance locating pt's caregiver or family members number...Pt. was unable to provide any additional information...MSW called the...Sheriff's department for a public call for services requesting that an emergency contact for the pt be provided by the facility and that a contact name and number for the facility be provided..." c. On March 26, 2024, at 3:50 p.m., "...LCSW (Licensed Clinical Social Worker) received a phone call back from (Name of family member)...who shared that patient was at (Name of SNF) for a few months and was told that patient was going to be discharged to an ALF (assisted living facility)...reported he was not told of another discharge plan and has no idea why patient would have ended up in (name of city different from the original location of discharge)...LCSW contacted (name of SNF)...and was transferred to a social worker...(name of SNF SW) reported that patient was supposed to go to a board and care in (name of city). (Name of SNF SW) shared that when patient got to the board and care they refused to accept him as they reported he was higher level of care than (Name of SNF 1) first reported. (Name of SNF SW) then reported that she began to contact various board and care and assisted living facilities in order to find alternate placement...board and care (Name of location of B & C 2) accepted patient and that' s why patient was transported there (referring to B & C 2). (Name of SNF SW) reported that she spoke to (Name) at the facility and accepted patient. LCSW contacted (Name of the person initially contacted in B & C 2 by SNF SW), after a few seconds it was evident (Name provided by the SNF SW as her contact in B & C 2) was not a board and care administrator and instead a resident of a board and care...LCSW was informed by (Name of SNF SW) that (Name of SNF 1)'s sister facility (Name of SNF 2) would accept patient..." A review of the facility's policy and procedure titled, "Discharge Summary and Plan," revised December 2016, indicated, "When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment ...5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include a. Where the individual plans to reside; b. Arrangements that have been made for follow-up care and services ... 7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan ...10. Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. Data used in helping the resident select an appropriate facility includes the receiving facility's: a. standardized patient assessment data; b. quality measure data; and c. data on resource use ...A member of the IDT will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place ..." Based on interview and record review, it was determined that the facility failed to arrange a safe and orderly discharge for Patient 2, when the facility arranged for the patient to be transported to a Board and Care 2 (B & C -a care provider with a lower-level care compared to a Skilled Nursing Facility [or Nursing Home]), without appropriate arrangement with Patient 2, Patient 2's family, and the receiving facility. This failure of the facility resulted in Patient 2 being left outside B & C 2, alone, unsupervised, and without certainty of being admitted to the board and care. Patient 2 was transferred to the GACH, due to B & C 2 being unaware of where the patient came from and behavior issues. In addition, this failure of the facility to ensure safe and orderly discharge is a substantial factor that can cause direct psychological harm to Patient 2. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.