Other·October 19, 2023

On 9/7/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about Resident 1's discharge plan process. The facility failed to ensure a safe discharge plan for Resident 1 in accordance with the facility's policy and procedures titled "Transfer and Discharge", dated 10/24/2022, evidenced by not conducting an interdisciplinary (IDT- a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) team meeting prior to discharge. As a result, Resident 1 was discharged to a lower level of care facility (a facility that provides less services than a skilled nursing facility) who was not able to care for Resident 1 and Resident 1 was admitted to General Acute Care Hospital (GACH) on the same day. A review of Resident 1's Admission Record (Face Sheet) dated 7/19/2021, indicated the facility admitted Resident 1 initially on 11/25/2011 and with the most recent readmission to the facility on 7/19/2021 with diagnoses that included amputation (the loss or removal of a body part such as a finger, toe, hand, foot, arm or leg) of the left arm at the left elbow, seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements including stiffness, twitching or limpness), dependence on supplemental oxygen (requires extra oxygen for daily living) and muscle weakness. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/22/2023, indicated Resident 1 ' s cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) is moderately impaired. Resident 1 required one person physical assist with bed mobility, dressing, eating, toilet use, personal hygiene and two person physical assist with transfer. A review of Resident 1's History and Physical (H&P) dated 9/30/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's physician order summary dated 8/30/2023, indicated Resident 1 had a discharge physician order to discharge to a board and care (BC) facility (a facility that provides non-skilled health care services) on 8/31/2023 with home health services (skilled health care services delivered directly to a patient's home) for physical therapy and nursing services (services provided by a licensed nurse for resident needs) for medication management. A review of Resident 1's Discharge Summary document dated 8/31/2023, indicated Resident was dependent (individual needs another person to perform the task completely and totally for the individual) for bed mobility, transfer, eating, toileting, and ambulation. During an interview on 9/7/2023 at 3:26 PM with the Operator (OP) of the BC facility, OP stated Resident 1 arrived at the BC facility on 8/31/2023 in a wheelchair. Upon arrival to the facility, Resident 1 was upset and was complaining but the OP was unable to understand what the Resident 1 was upset about. OP stated Resident 1 threw himself onto the floor from the wheelchair and with the assistance of staff they were able to return Resident 1 back to the wheelchair. Resident 1 then threw himself back onto the floor and was screaming and banging the cabinets. OP stated she was scared for Resident 1's safety, so she called 911 (phone number used to call emergency service personal) for emergency medical services (EMS- ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) to transfer Resident 1 to the GACH. Upon EMS arrival, Resident 1 refused to be transferred to GACH. EMS personal assisted Resident 1 back into the wheelchair. OP stated that about one hour later Resident 1 threw himself back on to the ground and was concerned that Resident 1 would hurt himself and she called EMS for assistance. OP stated EMS personal arrived at the BC and transferred Resident 1 to GACH for higher level of care. During an interview on 9/7/2023 at 3:40 PM with the Skilled Nursing Facility ' s (SNF's) Occupational Therapist Assistant (OTA- an assistant healthcare provider who helps a person improve his/her ability to perform daily tasks), OTA stated Resident 1 was a long term resident in the facility, and he was totally dependent on staff for bed mobility, transferring, eating, dressing and toileting. OTA stated Resident 1 required assistance with transferring from the bed to the wheelchair and used a stand up lift (an assistive device used to assist a person from a laying position to a sitting position). Resident 1 had difficulty balancing himself in a wheelchair. OTA stated Resident 1 required staff assistance with feeding because the resident would get tired and only had use of his right hand. During an interview on 9/7/2023 at 3:50 PM with Social Services Director (SSD), SSD stated that prior to Resident 1's discharge, the facility did not conduct an IDT meeting. SSD stated that an IDT meeting should have been completed prior to discharging Resident 1 to a lower level of care facility. During an interview on 9/7/2023 at 3:58 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she has provided care to Resident 1 prior to the resident's discharge and that Resident 1 required assistance when taking medications by mouth. During an interview on 9/7/2023 at 4:20 PM during an interview with the Director of Nursing (DON) and the Administrator (ADM), the DON and the ADM confirmed and stated the facility should have conducted an IDT prior to discharging Resident 1 to a lower level of care facility. A review of the facility's policy and procedures titled "Transfer and Discharge", dated 10/24/2022, indicated, "The purpose to ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to continuing care provider ...when the facility anticipates a resident's discharge to a lower level of care or to another nursing facility, the IDT with the assistance of the resident and his/her responsible party, will develop a discharge summary and post-discharge plan to assist the resident to adjust to his or new living environment. Appropriate IDT members will educate the resident or his/her responsible party regarding the discharge plan issues and will assist the resident with discharge plans". The facility failed to ensure a safe discharge plan for Resident 1 in accordance with the facility's policy and procedures titled "Transfer and Discharge", dated 10/24/2022, evidenced by not conducting IDT team meeting prior to discharge. As a result, Resident 1 was discharged to a lower level of care facility who was not able to care for Resident 1 and was admitted to the General Acute Care Hospital (GACH) on the same day. The above violations had direct or immediate relationship to the health, safety, or security of Residents 1.