Health inspection·July 16, 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 permit Resident 1 to return back to Skilled Nursing Facility 1 (SNF 1) from a general acute care hospital (GACH) for one of three sampled residents (Resident 1). As a resulted, GACH transferred Resident 1 to SNF 2 which was not the resident's preference. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to SNF 1 on 6/7/2024, with a diagnosis but not limited to anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), unspecified asthma (chronic lung disease that causes the bronchial airways in the lungs to narrow and swell, making it difficult to breathe). A review of Resident 1's History and Physical dated 6/10/2024, indicate Resident 1 had the capacity to make medical decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 6/11/2024, indicated Resident 1 had moderately impaired cognitive (mental ability to make decisions) skills for daily living. During an interview on 7-16-2024 at 8:54 am, the Admissions Director (AD) stated AD never told SNF 1 Administrator or the Director of Nursing (DON) that AD spoke with the Case Manager at the GACH regarding Resident 1 not wanting to return back to SNF 1. The AD stated AD never received a call from any of the GACH's Case Managers or Discharge Planners regarding readmitting Resident 1 back to SNF 1. The AD stated the administrator told AD the resident did not want to return back to SNF 1. During an interview on 7-16-2024 at 10:10 am, the Administrator stated there was no documentation in the nurse's progress notes, Situation Background Assessment Recommendation (SBAR), Change of Condition (COC) or transfer sheet indicating that Resident 1 stated he did not want to return back to the facility. During a concurrent record review with the Administrator of the facility census a new Resident 4 was admitted to the facility on [DATE] and placed in Resident 1's room and bed. The Administrator stated she never heard Resident 1 say that the resident did not want to return to SNF 1. The Administrator stated SNF1's AD spoke with a Case Manager (unable to recall the name) at the GACH that the case manager informed the AD that Resident 1 did not want to return back to SNF 1. The Administrator stated the AD told the Administrator that Resident 1 did not want to return back to SNF 1. The Administrator stated she should have discussed with Resident 1 regarding the resident's wishes to Page 1 of 2 555786 555786 07/16/2024 Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few return back to SNF 1. The Administrator stated, typically when residents are sent to the hospital the resident sign a 7-day bed hold and can return back to the facility. During a concurrent record review on 7-16-2024 at 10:41 am, with the Director of Nursing (DON). Resident 1's Physicians orders dated 6-24-2024 were reviewed. There were no physicians order for 7-day bed hold for Resident 1. There was no documentation on 6-24-2024 (day Resident 1 was transferred to the GACH) that Resident 1 stated he did not want to return back to SNF 1. During an interview on 7-16-2024 at 11 am, the DON stated the nurse that got the order to transfer Resident 1 to the GACH should have obtained a physician's order for a 7-day bed hold for Resident 1. The DON stated she never heard Resident 1 say that the resident did not want to return back to the facility. The DON stated she should have talked to Resident 1 or followed up with GACH's Case Manager prior to GACH transferring the resident to SNF 2. During record review on 7-22-2024 at 11:35 am, the Administrator sent an email to the State Agency (SA) indicating that the Administrator never spoke to a Case Manager at the GACH regarding Resident 1. A review of the facility's policy and procedure titled Bed-Holds and Returns revised 3/2017, indicated: . Policy Interpretation and Implementation: 7. There resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there is not an available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available. 555786 Page 2 of 2