Health inspection·May 3, 2024

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a follow up call and /or assessment was done to verify durable medical equipment was provided to Resident 1 as ordered (DME, are equipment and supplies for everyday or extended use). Residents Affected - Few This failure posed a risk for an unsafe transition from the facility to the home setting. Findings: During an interview on 4/4/24 at 1:47 p.m., Resident 1's family member 1, stated, when the resident was discharged from the facility on 3/5/24, the family member was told by the facility's Social Service Director (SSD), that the DME would be delivered at their house. The family member stated, they did not receive the delivery of the DME. Further stated, they had to move the resident around the house for safe transfers, and after a few days, the family had to purchase a wheelchair to safely move the resident around the house because the resident could not walk. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis that affects only one side of your body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (commonly known as stroke, caused by a blockage in a blood vessel in the brain, leading to brain damage). The admission record also indicated; the resident was discharged to home from the facility on 3/5/23 at 12:30 p.m. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/5/24, under Section GG titled, Functional Abilities and Goals indicated, Resident 1 was unable to walk and used a wheelchair for mobility. The MDS also indicated, Resident 1 was dependent in the assistance of 2 or more helpers on surface-to-surface transfer (such as when transferring between bed and chair or wheelchair). Review of the physician's order dated 2/27/24, indicated an order for home health services referrals for Registered Nurse, Physical Therapy and Occupational Therapy services. The physician's order also indicated an order for DME of a wheelchair, hospital bed and patient lift (home health services are wide range of health services provided in a home for an illness ; patient lift is an equipment designed to lift and transfer patients from one place to another). Review of Resident 1's Discharge Summary dated 3/5/24, indicated, .discharged to daughter's house on 3/5/24. Home health ordered . home health to deliver DME to daughter's house. Page 1 of 2 555292 555292 05/03/2024 Alhambra Post Acute 331 Ilene Street Martinez, CA 94553

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/4/24 at 2:50 p.m., with SSD, stated she arranged home health services for Resident 1 prior to his discharge and the home health agency (HHA) was supposed to arrange for the delivery of the DME to the daughter's house. Stated she should have made sure that the DME was delivered to the resident's daughter's house before Resident 1 was discharged to ensure that the resident was safe at home. SSD acknowledged that even if the HHA stated they would arrange for the DME delivery, it was still the SSD's responsibility to ensure that Resident 1 was discharged safely from the facility (Home Health Agency or HHA is a public agency or private organization which provides home health services). During another interview on 4/10/24 at 11:31 a.m., with SSD, stated she made a follow up phone call to the Resident 1's family, 72 hours after the resident was discharged from the facility to verify the resident's status . Stated she failed to ask if the resident had already received the DME. Also stated, she had no documentation of the follow up phone call. Stated she should have verified the status of the DME delivery with the resident's family. Further stated, she did not make a follow up call to the HHA after the resident was discharged from the facility to verify if the DME were delivered. During a concurrent interview and record review on 4/23/24 at 9:45 a.m., with the Director of Nurses (DON), Social Services Director Job Description , dated March 2017 indicated, .Essential duties of SSD includes . assisting in discharge planning with appropriate agencies entities or individuals to include agency services equipment and agency referrals coordinates with interdisciplinary team . The DON acknowledged, the SSD should have followed up with the HHA and followed up on the DME before the resident's discharge. Further stated, Resident 1 should not have been discharged from the facility without the DME at home to ensure safety. Also stated, she could not find a documentation of Resident 1's post-discharge plan in the resident's medical records (a post-discharge plan is a plan developed by the facility to ensure that all the services the resident need are in place when the resident gets discharged from the facility). During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, revised October, 2022, the P&P indicated, . When a resident's discharge is anticipated, . post-discharge plan is developed to assist the resident with discharge . the post discharge plan is developed by the care planning/interdisciplinary team (IDT), with the assistance of the resident and his or her family and includes: .arrangements that have been made for follow-up care and services; .how the IDT will support the resident or representative in the transition to post-discharge care . (Interdisciplinary team or IDT is a group of individuals representing different departments of the facility). The P&P also indicated; a copy of the post-discharge plan should be filed in the resident's medical records. 555292 Page 2 of 2