Health inspection·March 18, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure to discharge on e of three sample selected residents (Resident 1) safely to an appropriate place, when the facility discharged Resident 1 to an independent living facility while Resident 1 needed a higher level of care. Residents Affected - Few This deficient practice resulted in Resident 1 eloping (leaving a facility when doing so may present an imminent threat to the patient's health or safety) from the independent living facility and found by police wandering the streets resulting in hospitalization. Finding: A review of Resident 1's Face Sheet indicated, Resident 1 was admitted to the facility with multiple diagnoses including schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real), seizures (episodes of uncontrolled and abnormal firing of brain cells that can cause physical changes in attention or behavior such as uncontrollable shaking with rapid and rhythmic body movements), major depression and dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a concurrent interview and record review on 2/15/24 at 11:14 a.m. with Social Worker (SW), SW reviewed the Social Services Notes and stated Resident 1 needed a higher level of care and that was a mistake to discharge Resident 1 to an independent living facility. During an interview on 2/15/24 at 11:30 a.m. with Medical Doctor (MD), MD stated Resident 1 needed supervision and should be discharged to a facility with a higher level of care than an independent living facility. A review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), section C0700, dated 1/27/24, the MDS indicated Resident 1 had short term and long-term memory problems. A review of Resident 1's Care Plan for discharge, initiated 9/28/23, indicated .Goal, will be discharge to appropriate placement which will meet individualized care needs . A review of Resident 1's MD Progress Note, dated 12/17/2023, indicated . patient continued to be aggressive and violent, wanting to leave Against Medical Advice (AMA), patient doesn't have capacity due to dementia . Page 1 of 3 555418 555418 03/18/2024 St Francis Healthcare Center 718 Bartlett Ave Hayward, CA 94541

F 0624 Level of Harm - Minimal harm or potential for actual harm During a review of History & Physical (H&P), from the hospital, Resident 1 was admitted to the hospital with multiple diagnoses including altered mental status and major neurocognitive disorder due to unspecified disease (unspecified Dementia). H&P indicated . Per ER (Emergency Room) MD (Medical Doctor) earlier patient was trying to leave, does not know where she lives, to her patient appeared demented to make decision . Residents Affected - Few A review of the facility's policy and procedure Transfer or Discharge, Emergency, revised 2018, indicated .Residents will not be transferred unless .The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility . Based on interview and record review, the facility failed to ensure to discharge on e of three sample selected residents (Resident 1) safely to an appropriate place, when the facility discharged Resident 1 to an independent living facility while Resident 1 needed a higher level of care. This deficient practice resulted in Resident 1 eloping (leaving a facility when doing so may present an imminent threat to the patient's health or safety) from the independent living facility and found by police wandering the streets resulting in hospitalization. Finding: A review of Resident 1's Face Sheet indicated, Resident 1 was admitted to the facility with multiple diagnoses including schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real), seizures (episodes of uncontrolled and abnormal firing of brain cells that can cause physical changes in attention or behavior such as uncontrollable shaking with rapid and rhythmic body movements), major depression and dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a concurrent interview and record review on 2/15/24 at 11:14 a.m. with Social Worker (SW), SW reviewed the Social Services Notes and stated Resident 1 needed a higher level of care and that was a mistake to discharge Resident 1 to an independent living facility. During an interview on 2/15/24 at 11:30 a.m. with Medical Doctor (MD), MD stated Resident 1 needed supervision and should be discharged to a facility with a higher level of care than an independent living facility. A review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), section C0700, dated 1/27/24, the MDS indicated Resident 1 had short term and long-term memory problems. A review of Resident 1's Care Plan for discharge, initiated 9/28/23, indicated .Goal, will be discharge to appropriate placement which will meet individualized care needs . A review of Resident 1's MD Progress Note, dated 12/17/2023, indicated . patient continued to be aggressive and violent, wanting to leave Against Medical Advice (AMA), patient doesn't have capacity due to dementia . 555418 Page 2 of 3 555418 03/18/2024 St Francis Healthcare Center 718 Bartlett Ave Hayward, CA 94541

F 0624 Level of Harm - Minimal harm or potential for actual harm During a review of History & Physical (H&P), from the hospital, Resident 1 was admitted to the hospital with multiple diagnoses including altered mental status and major neurocognitive disorder due to unspecified disease (unspecified Dementia). H&P indicated . Per ER (Emergency Room) MD (Medical Doctor) earlier patient was trying to leave, does not know where she lives, to her patient appeared demented to make decision . Residents Affected - Few A review of the facility's policy and procedure Transfer or Discharge, Emergency, revised 2018, indicated .Residents will not be transferred unless .The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility . 555418 Page 3 of 3