Other·June 21, 2024

Title 22 72519 (a) Patient Transfer California Code of Regulations, Title 22, section 72519. Patient Transfer. (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate transfer of patients. Completed and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at the time of transfer. California Code of Regulations, Title 22, section 72523 Patient Care Policies and Procedures. (a) Written patient care and policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 42 CFR 483.21 (c) (1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility’s discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and— (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. On April 4, 2024, at 10:10 a.m., an unannounced visit to the facility was conducted to investigate a quality of care and treatment issue. It was determined that the facility failed to ensure Patient A’s discharge plan to an assisted living facility (provides support with daily activities but does not offer extensive medical care) was re-evaluated and modified when the patient developed a coccyx (tailbone area) Stage 4 pressure injury (bed sore with severe tissue damage with exposed bone, tendon [tissue that connects the muscle to the bone], and muscle) prior to discharge from the facility. In addition, the facility failed to ensure continuity of care and treatment for Patient A's pressure injury was arranged during the patient's discharge to the assisted living facility. These failures resulted in Patient A's discharge to a lower level of care facility who was unaware of the existence of the pressure injury. In addition, there was no treatment provided to Patient A's pressure injury which led to the worsening of the Stage 4 pressure injury while at the assisted living facility, causing a general acute care hospital (GACH) transfer. A review of Patient A's document titled, "Admission record," provided by the facility on April 4, 2024, indicated Patient A was admitted to the facility on November 3, 2022, with diagnoses which included paraplegia (paralyzed legs). A review of Patient A’s "Nursing Progress Notes," dated May 19, 2023, indicated, "...Patient has old white scar from his open sore on his back (coccyx area) was closed prior to fall now has opening..." A review of the facility document titled, "Change in Condition Evaluation," dated May 19, 2023, indicated, " ...s/p (status post) fall ...area of fragile scar tissue to coccyx noted as reopened ...site...coccyx...length- 2 cm. (centimeters- unit of measurement) x width 1.5 cm. x depth- 0.2 cm....Stage- 4..." A review of Patient A's "Weekly Pressure Ulcer Report," indicated the following: -Dated May 19, 2023, "...Pressure Sore Description...Coccyx...Length... 2...Width...1.5...Depth 0.2...Stage IV (Stage 4) ..." -Dated May 26, 2023, "...Pressure Sore Description...Coccyx...Length ...2...Width...1.5 ...Depth 0.1...Stage IV..." A review of Patient A's "Physician Order," dated May 19, 2023, indicated, "...coccyx: cleanse with (w/) NS (Normal Saline - a mixture of salt and water used for cleaning wound), pat dry, apply collagen (to help make tissue strong and resilient), cover w/dry dressing once daily...for re-open of pressure injury stage 4..." A review of Patient A's "Physician Order," dated May 30, 2023, indicated, "...May discharge to (Name of the facility) Assisted Living Facility ...ON 5/28/23 (May 28, 2023) ..." A review of Patient A's "Discharge Summary," (undated) indicated, "...Discharge Date...5-28-23 (May 28, 2023) ...Skin Condition at Discharge...blank (no entry) ...Home Nursing...Pending..." Further review of Patient A's progress notes did not indicate documentation that Patient A's Stage 4 pressure injury was discussed with the receiving assisted living facility prior to discharge on May 28, 2023. A review of the progress notes did not indicate documentation that Patient A's discharge plan was discussed by the Interdisciplinary Team (IDT - integrating multiple disciplines through collaboration) to modify the discharge plan due to Patient A's Stage 4 pressure injury. On May 20, 2024, at 1 p.m., during an interview with the Assisted Living Assistant Administrator (AA), she stated the following: 1. The skilled nursing facility provided a copy of the "Physician's Report for Residential Care Facilities for the Elderly," for Patient A on April 12, 2023, to provide information on the status of the patient, his diagnosis, and other medical conditions. 2. She went to the facility to evaluate Patient A two days prior to the patient's discharge, and she asked the Certified Nursing Assistant and the Charge Nurse about the skin condition of Patient A. The AA stated the staff told her Patient A had no wounds. 3. If she had been aware of Patient A's wound on the coccyx, she would not have admitted the patient to the assisted living facility. 4. The assisted living facility could not provide care for a patient with a Stage 4 pressure injury. 5. Patient A was admitted to their facility (assisted living facility) on May 28, 2023, and was transferred to a GACH on May 30, 2023. A review of Patient A’s document provided to the assisted living facility by the skilled nursing facility titled, "PHYSICIAN ' S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE)," (undated) indicated, "... (name of the facility) ...PRIMARY DIAGNOSIS...ESSENTIAL. HYPERTENSION...PHYSICAL HEALTH STATUS...History of Skin Condition or Breakdown...NO..." A review of Patient A's document from the assisted living facility titled, "Narrative Notes," dated May 30, 2023, indicated, "...Patient has an open wound in tailbone she asked patient if he was informed, and patient did not know anything about it...went to check on patient and immediately informed patient that...have to send him out to ER (emergency room) ..." On May 20, 2024, at 4:20 p.m., during an interview with the skilled nursing facility (SNF) Registered Nurse (RN), the RN stated the IDT has to re-evaluate and update the discharge plan if the patient has a change in medical condition. The RN stated Social Services had to coordinate with the assisted living staff. The RN stated when a patient is discharged to another facility, the patient's representative would be provided with a recapitulation of the patient's stay at the facility, including information on medications and skin conditions. On May 20, 2024, at 4:40 p.m., during a concurrent interview and review of Patient A's progress notes dated April 19, 2023, to May 28, 2023, the SNF Director of Nursing (DON) stated the discharge planning was initiated on April 19, 2023. The DON further stated Patient A developed a Stage 4 pressure injury on May 19, 2023. The DON stated the presence of Patient A's pressure injury should have been coordinated with the assisted living facility. The DON stated the facility did not have documentation showing that nursing staff communicated the presence of a Stage 4 pressure injury to the assisted living facility. The DON stated there was no documentation Patient A's discharge plan was discussed and re-evaluated. The DON stated Patient A should not have been discharged to an assisted living facility. On May 21, 2024, at 8:41 a.m., during an interview with the Social Service Assistant (SSA), the SSA stated she was in-charge of Patient A's discharge planning. The SSA stated she coordinated Patient A's discharge to the assisted living facility; and that she was not aware Patient A had developed a pressure ulcer while residing at the SNF. The SSA stated, if she had been aware of the patient's skin condition, she would have called the assisted living to inform them of the patient’s current condition; and she stated she would have held the discharge to modify the discharge plan. A review of the facility's policy and procedure titled, "Transfer and Discharge," dated April 1, 2023, indicated, "...Purpose...to provide complete, safe and appropriate discharge planning and necessary information to the continuing provider...Discharge planning continues throughout the stay...If the information in the notice changes prior to the transfer or discharge, the Facility will provide updated information to the recipients of the notice as soon as practicable ...if the changes to the notice are significant...a new notice must be given that clearly describes the change(s)..." A review of Patient A's document from the GACH titled, "ED (Emergency Department) Physician Record," dated May 30, 2023, indicated, "...from (name of assisted living) to the ED for the evaluation of a coccyx wound...the patient has a bed sore (also known as pressure injury) that progressively worsened which staff noticed this morning...Physical Examination...back...sacrum (lower part of the back between the tailbone [coccyx] and the pelvis [bony structure at the base of the spine])...green fibrinous exudate in wound approx. (approximately) 5 cm in diameter...Impression and Plan...Sacral decubitus (bedsore) ulcer...Infected decubitus ulcer..." A review of Patient A's document from the GACH titled, "Wound Care Note," dated May 31, 2023, indicated, "...Dx (Diagnoses)...Sacral Wound...Sacral Stage 4 Pressure Injury...6.0 x (by) 4.0 x 3.3 cm with undermining (tissue damage beneath the surface of the skin surrounding a wound) present from 8:00-12:00, deepest at 10:00 measuring 5.2 cm..." Based on interview and record review, it was determined that the facility failed to ensure Patient A’s discharge plan to an assisted living facility was re-evaluated and modified when the patient developed a Stage 4 pressure injury prior to discharge from the skilled nursing facility. In addition, the facility failed to ensure continuity of care and treatment for Patient A's pressure injury was arranged during the patient's discharge to the assisted living facility. These failures resulted in Patient A's discharge to a lower level of care facility who was unaware of the existence of the pressure injury. In addition, there was no treatment provided to Patient A's pressure injury which led to the worsening of the Stage 4 pressure injury while at the assisted living facility, causing a GACH transfer. This violation, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.