Health inspection·April 20, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of the notice of discharge and the reasons for the move in writing to a representative of the Office of the State Long-Term Care Ombudsman and the residents legal guardian for one (Resident #1) of five residents reviewed for admission/transfer/discharge rights. The facility failed to ensure the Long-Term Care Ombudsman and resident's guardian was notified that Resident #1 was denied readmission to the facility after being sent to the behavioral hospital. This failure could put residents at risk of not having an opportunity to appeal discharge, and not having their rights honored regarding facility-initiated discharges, and not receiving needed care. Findings include: Record review of Resident #1's face sheet, not dated, indicated Resident #1 was a [AGE] year-old female who initially admitted on [DATE] and a most recent re-admission date of 3/7/23 with diagnoses including Alzheimer's Disease, hypertension (high blood pressure), and major depressive disorder. Resident #1 was on the secured locked Alzheimer's unit and transferred on 3/14/23 to a behavioral hospital for treatment and medication adjustment due to aggressive behaviors. Record Review of Resident #1's Transfer/Discharge letter dated 3/30/23 documented the resident was discharged effective immediately. The reason for discharge was described as based on safety of other residents and staff due to Resident #1's aggressive behavior. Record review of Resident #1's EMR nursing progress notes revealed she was admitted to a behavioral hospital on 2/27/23 and readmitted to the facility on [DATE]. She was discharged to another behavioral hospital on 4/14/23 Record review of a Nursing progress note dated 3/9/23 at 4:20 PM revealed the resident had a resident-to-resident altercation with another resident. She became upset and was hitting furniture. She stated she did not want to live like this. Review of physician's progress note dated 3/9/23 by the psychiatrist revealed the Resident #1 was suffering from obsessions, delusions, and paranoia. The psychiatrist stated she was a danger to herself and others. The psychiatrist ordered Trazodone 50 mg daily in the evening. Review of nursing progress note dated 3/13/23 at 11:05 AM revealed, the resident was verbally Page 1 of 2 676148 676148 04/20/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0623 aggressive to several other residents in the Dining room and hit the DON in the arm and screamed at her. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's Discharge MDS dated [DATE] documented in part her BIMS was 9 (which indicated moderate cognitive impairment) she displayed verbal and physical behaviors such as screaming, hitting, and slapping at others. Residents Affected - Few Review of discharge letter provided to the residents legal guardian by the facility dated 3/30/23 stated the resident was discharged from the facility, effective immediately. During an interview with Resident #1's court appointed guardian on 4/18/23, at 10:35 AM she stated she had agreed to the transfer to the psychiatric hospital and the DON, SW, or the Administrator had not told her Resident #1 would not be allowed to return to the facility after treatment. She stated she did not hear of the discharge until she was notified by the behavioral hospital that the facility was ready for discharge and refused to accept the transfer of the resident back to the facility. She stated she contacted the facility administrator by phone on 3/30/23 and asked them if the facility would deny admission if she brought her to the facility immediately after she was dismissed from the behavioral unit. The facility DON confirmed the resident was not going to be admitted . The guardian stated stated she had to find alternate placement for Resident #1 on that day due to the facilities refusal to accept Resident #1. During an interview via telephone on 4/19/23 at 11:25 am, the Ombudsman said she and the resident's court appointed legal guardian had received a discharge letter from the facility stating the resident was denied readmission to the facility and her discharge was effective immediately on3/30/23. The Ombudsman said the facility did not assess the resident after treatment at the behavioral unit before denying admission; they just issued an immediate discharge notice. During an interview on 4/19/23 at 1:57 p.m., the DON and the Administrator both said the social worker was responsible for assisting residents by seeking alternate placement at the time of discharge. The DON stated the resident was a danger to herself and others, and the decision to not accept the resident was made by her corporate supervisors on 3/30/23. On 4/19/23 a copy of the facility's policy on discharge was requested the facility did not provide a discharge policy but did provide a copy of the admission agreement for review. Record review of the facility's admission agreement, dated revised 10/19/22, documented in part: Except in an emergency, the resident shall not be discharged or transferred without prior consultation with the resident, resident's attending, physician, and the resident's responsible party. Written notification describing the reasons for the transfer or discharge. Written notice will be given to resident/responsible party for all planned discharges and transfers. unless waived by the resident or responsible party. 676148 Page 2 of 2