Health inspection·December 24, 2024

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to readmit Resident 1 to the facility after being cleared by the general acute care hospital (GACH) to return to the facility. This deficient practice of not allowing Resident 1 to be readmitted to the facility had the potential to displace the resident. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), encephalopathy (a brain disorder or disease that affects the brain's function), and heart failure (a condition where the heart is unable to pump enough blood to meet the body's needs resulting in inadequate oxygen delivery to organs and tissues). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 1 was dependent on staff for showering, dressing, and personal hygiene. The MDS indicated Resident 1 had a feeding tube (flexible plastic tube that delivers nutrition, fluids, and medications directly into the digestive system), tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs) and was receiving oxygen therapy (a medical treatment that involves administering extra oxygen to patients with breathing problems). During a review of Resident 1's Discharge Summary Report, dated [DATE], the Discharge Summary Report indicated Resident 1 was to be discharged to an acute care hospital due to altered mental status. During a review of Resident 1's general acute care hospital (GACH) records titled, Consultation Notes, dated [DATE], the Consultation Notes indicated Resident 1 was no longer restrained. The Consultation Notes indicated the GACH notified the facility on [DATE]. During a review of the facility's Census, dated [DATE], the Census indicated there were three male rooms available. Page 1 of 2 555719 555719 12/24/2024 Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250

F 0626 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's GACH records titled, Discharge Planning Progress Notes, dated [DATE], the Discharge Planning Progress Notes indicated the facility had no open beds available. During a review of the facility's Census, dated [DATE], the Census indicated there were three male rooms available. Residents Affected - Few During a telephone interview on [DATE] at 4:10 p.m. with the GACH's Clinical Social Worker (CSW), the CSW stated the facility did not want to take Resident 1 back. The CSW stated Resident 1 was transferred to the GACH on [DATE] due to mental changes. The CSW stated Resident 1 had to be placed in restraints and was medically cleared to returned to the facility on [DATE] (2 days later). The CSW stated the facility denied Resident 1's readmission due to the resident being restrained. The CSW stated once Resident 1's restraints were discontinued on [DATE], the GACH called the facility on [DATE] and [DATE] and was told there were no beds available on [DATE] and [DATE]. During a concurrent interview and record review on [DATE] at 11:00 a.m. with the facility's admission Coordinator (AC), the Census, dated [DATE] and [DATE] was reviewed. The Census indicated there were three male beds available. The AC stated Resident 1 was in the Sub-Acute (a specialized nursing specialty that provides care for patients who need more intensive care) unit of the facility and was transferred to GACH. The AC stated the facility was not able to readmit Resident 1 if he was restrained. The AC stated the GACH contacted her on [DATE] to arrange Resident 1's readmission to the facility and the AC informed the Administrator (ADM) and Director of Nursing (DON). The AC stated she was not sure if the Administrator and DON followed up with the GACH about readmitting Resident 1. During an interview on [DATE] at 11:15 a.m. with the ADM, the ADM stated Resident 1 was in the Sub-Acute unit of the facility and were able to manage the resident. The ADM stated Resident 1 was sent to the GACH did not readmit the resident due the restraints. The ADM stated the facility would readmit Resident 1 if the resident was clinically cleared and if there was a bed available. The ADM stated there was a bed available for Resident 1. During a concurrent interview and record review on [DATE] at 12:34 p.m. with the DON, the Census, dated [DATE] to [DATE] was reviewed. The Census indicated there were male beds available from [DATE] to [DATE]. The DON stated Resident 1 was transferred to the GACH on [DATE] due to altered mental behavior changes. The DON stated Resident 1 was in the Sub-Acute, unit of the facility and was pulling on his tracheostomy and required close supervision. The DON stated in order for Resident 1 to be readmitted to the facility, the resident would have to be restraint free for 48 hours straight. The DON stated there were male beds available from [DATE] to [DATE]. The DON stated when Resident 1's restraints were discontinued on [DATE] for 48 hours straight and a bed was available the facility could readmit the resident. During a review of the facility's policy and procedure (P&P) titled, readmission to the facility, dated 3/2017, the P&P indicated, residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. During a review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, dated 10/2022, the P&P indicated, residents who were to return to the facility after the state bed-hold period has expired are allowed to return to their previous room if available or immediately to the first available bed. 555719 Page 2 of 2