Health inspection·April 17, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a safe and appropriate discharge for one of three sampled residents (Resident 1). Residents Affected - Few As a result, Resident 1 was inappropriately discharged to an independent living facility (ILF; a residence for individuals who have the mental capacity to live independently without medical or physical assistance with their daily living tasks) that placed Resident 1 at risk for harm and/or injury. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was re-admitted to the facility on [DATE], and discharged on 2/16/24 to an ILF with diagnoses that included a history of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbances. A record review of Resident 1 ' s History and Physical dated 9/1/23 completed by Resident 1 ' s medical doctor (MD) indicated .This resident does NOT have the capacity to understand and make decisions . A record review of Resident 1 ' s quarterly rehabilitation screen dated 12/19/23 indicated .Pt (patient) [sic] continues with cognitive (the mental process involved in knowing, learning, and understanding) impairment that dec (declines) [sic] her safety and awareness . A record review of Resident 1 ' s MD note dated 1/22/24 was conducted. The MD note indicated .She is wandering about and trying to get to a locked unit [sic] followed by Psychiatry.confused and not able to follow directions . A record review of Resident 1 ' s MD note dated 1/25/24 was conducted. The MD note stated .She still is really confused [sic] and we are trying to get her to a locked unit for dementia . A record review of Resident 1's discharge (completed for the purpose of discharging the resident) Minimum Data Set (MDS- used to develop a plan of care) dated 2/16/24, indicated Resident 1 had severe cognitive loss with a Brief Interview for Mental Status (BIMS- cognitive status 0-7 severe impairment, 8-12 moderately impaired, 13-15 cognitively intact) score of 0 out of 15 points. A record review of Resident 1 ' s discharge MDS dated [DATE] included information on Resident 1 ' s usual performance with self-activities of daily living (ADL: skills required to manage one's basic physical needs, including personal hygiene or grooming, dressing, toileting, transferring or Page 1 of 2 555804 555804 04/17/2024 Victoria Post Acute Care 654 S. Anza El Cajon, CA 92020

F 0624 Level of Harm - Minimal harm or potential for actual harm ambulating, and eating). The information was gathered within the last three days before Resident 1 was discharged . Per this record, Resident 1 was not fully independent with ADLs. Resident 1 required moderate assistance (helper lifts, holds, or supports trunks [torso] or limbs [arms, legs] but provides less than half the effort) with self-care ADLs that included showering, dressing, personal hygiene, bed mobility, and tub/showering transfers. Residents Affected - Few A record review of Resident 1 ' s clinical record related to self-medication administration (the ability of an individual to administer his/her own medication) was conducted. There were no records that indicated Resident 1 was evaluated for safe self-medication administration. On 4/15/24 at 10:46 A.M., an interview was conducted with the social services director (SSD). The SSD stated she assisted the case manager with discharge placements. The SSD stated that residents who discharged to an ILF were usually independent residents who did not require assistance with ADLs, but it was her understanding that the ILF took care of individuals who had dementia. On 4/15/24 at 11:50 A.M., an interview and record review was conducted with the case manager (CM). The CM stated that Resident 1 was placed in an ILF .because it was the cheapest option. The CM reviewed Resident 1 ' s discharge notes and stated that Resident 1 was discharged to the ILF with her belongings and medications but was unable to find documentation related to safety evaluations for self-administration of medications. The CM stated Resident 1 had dementia with memory loss, required cueing (prompting/reminder), and was eating and walking independently without supervision when Resident 1 was at the facility. The CM stated it was determined that an ILF was considered because she thought the ILF provided 24-hour resident care, and that options such as locked units or assisted living were not available, and/or had wait lists. The CM stated, I think we should have looked at other safety concerns to evaluate such as self-medication administration, ADLs, and their [residents in facility] mental capacity prior to discharging our residents. The CM concluded that the safest discharge option would have been for Resident 1 to be discharged to a locked unit or an assisted living that specialized in dementia care. An interview with the Director of Nursing (DON) was conducted on 4/16/24 at 12:45 P.M. The DON stated that Resident 1 had memory deficits (loss) because of dementia, was able to walk around independently, and was not evaluated for self-medication administration or other safety evaluation because Resident 1 only required queuing. The DON acknowledged Resident 1 was not fully independent with ADLs and that an ILF was the last resort for Resident 1 to be discharged to. The DON acknowledged that the safest option would have been for Resident 1 to discharge to a locked unit for dementia care. A review of facility's discharge policy and procedure dated 1/20/22, Discharge Planning Process Policy, indicated .1b. Ensure that the discharge needs for each resident are identified on admission. 4. The Facility shall document, complete on a timely basis based on the resident ' s needs, and include in the clinical record, the evaluation of the resident ' s discharge needs and discharge plan . e. Consider . and the resident's .capacity and capability to perform required care, as part of the identification of discharge needs . 555804 Page 2 of 2