Other·August 11, 2023

The following reflects the findings of the California Department of Public Health during the investigation of an entity reported incident. Entity Reported Incident Number CA00846684 Representing the Department, HFEN # State Citation (B) was written. §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident- (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 06/21/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about the facility's refusal to readmit a resident. The facility failed to ensure it implemented its' policy regarding Bed-Holds and Returns, by failing to readmit Resident 1, who was transferred for an emergency treatment at a general acute hospital (GACH) on 02/03/2023. As a result, Resident 1's responsible party filed an appeal of the facility's refusal to readmit Resident 1 and a potential to cause unnecessary anxiety and emotional distress to Resident 1. A review of Resident 1's Admission Record indicated Resident 1 was admitted to facility on 6/10/2021 and readmitted on 1/19/2023, with the diagnoses including chronic kidney disease (Stage 3, kidneys are not filtering your blood & removing waste), glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight), muscle weakness, and urinary retention. The Minimum Data Set (MDS, a standardized comprehensive assessment tool) dated 12/21/2022, indicated Resident 1 was alert, had clear speech, able to understand and able to be understood with a BIMS score of 14 (alert). The resident required extensive assistance and two+ person physical assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. A review of the Physician's Order dated 2/3/2023, indicated an order to transfer Resident 1 to an acute care emergency room (ER) for further evaluation for a complaint of not feeling well, hematuria (blood in the urine), vaginal pain and discomfort. A review of the Department of Health Care Services Office of Administrative Hearings and Appeals' document titled, "Decision and Order" for the Resident 1's appeal case (Appeal No. RTR23-0523-861-SW), dated 6/5/2023, indicated "The appeal is GRANTED. The Skilled Nursing facility (SNF) has not met the legal requirements to involuntarily discharge [the Resident 1] (Resident). Therefore, the facility must readmit Resident 1 to the first available bed in a semi-private room at the facility." A review of the Department of Health Care Services Office of Administrative Hearings and Appeals' document titled, "Decision and Order" for the Resident 1's appeal case (Appeal No. RTR23-0523-861-SW), dated 6/5/2023, further indicated, "On 05/10/2023, Authorized Representative filed an appeal of the facility's refusal to readmit." During a telephone interview, on 6/21/2023 at 11:48 a.m., Resident 1's son stated he was very upset the facility did not permit the resident back. The son further stated the facility did not provide a Bed-Hold Notice and would not accept the resident back into the facility. During a tour of the facility on 6/21/2023 at 2:35pm, Resident 1 was not in the facility. A review of the facility's census for the day (06/21/2023) provided by the facility indicated Resident 1 had not been readmitted to the facility. During an interview with the Administrator, on 6/21/2023 at 3:30 p.m., the Administrator confirmed, and stated Resident 1 was not back to the facility. A review of the facility's policy and procedures titled, " Bed-Holds and Returns," with revised dated of 08/01/2022, indicated, " Prior to transfers and therapeutic leaves, residents or resident representatives will be informed of the bed-hold and return policy...If a Medicaid resident exceeds the state bed-hold period, he or she will be permitted to return to the facility, to his or her previous room (if available) or immediately upon the first availability of a bed. The facility failed to ensure it implemented its' policy regarding Bed-Holds and Returns, by failing to readmit Resident 1, who was transferred for an emergency treatment at a GACH on 02/03/2023. As a result, Resident 1's responsible party filed an appeal of the facility's refusal to readmit Resident 1 and a potential to cause unnecessary anxiety and emotional distress to Resident 1. The above violations had a direct relationship to the health, safety, and security of Resident 1.