Health inspection·March 17, 2022

F624 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. On 12/29/2021, the California Department of Public Health (CDPH - or State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to unsafe discharge. The facility failed to safely discharge Resident 1, who was blind and needed staff assistance with all activities of daily living (ADLs, such as personal hygiene, bathing, dressing, etc.). On 7/21/2021, Resident 1 was discharged to an independent living home (unlicensed independent living home). As a result, Resident 1 was taken to General Acute Care Hospital 1 (GACH 1) by the owner of the home. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 01/27/2021 with a diagnoses including metabolic encephalopathy (chemical imbalance in the blood affecting the brain causing personality changes), sepsis (a life-threatening complication of infection), acute pancreatitis (inflamed pancreas-small organ that helps with digestion), legally blind, and diabetes mellitus ((refers to a group of diseases that affect how the body processes the blood sugar [glucose])). A review of Resident 1's History and Physical exam, dated and completed by the attending physician on 02/26/2021, indicated the resident did not have capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 07/21/2021, indicated the resident was able to communicate, remember and make decisions. Resident 1 needed limited assistance from staff for all activities of daily living (ADLs such as personal hygiene, bed mobility, dressing, and transfers). A review of the Physician's Order for Resident 1, dated 07/20/2021, indicated to discharge the resident to an independent living home on 07/21/2021. A review of Resident 1's Discharge Summary/Post Discharge Plan of Care, dated and signed by resident on 07/21/2021, indicated Resident 1 needed assist with bathing, dressing, eating, personal hygiene, transfers, bed mobility, toilet use, and ambulation. On 12/29/2021 at 09:33 a.m., during an interview, Social Service (SS 1) stated Resident 1 initiated the discharge and Social Service Director (SSD) found the place for him, an independent living. The place had someone that cooked, cleaned, and did laundry. SS 1 stated there was no documentation SSD checked if the independent living was a licensed facility. On 02/22/2022 at 03:55 p.m., during an interview, the Independent Living Owner (ILO) stated he owned the house and rented it to Resident 1. ILO stated Resident 1 lived there independently, cooks for himself and did everything for himself. ILO stated he had a cleaning crew that went to the house once a month. On 02/03/2022 at 01:54 p.m., during an interview, Director of Nursing (DON) stated it was a mistake to discharge the resident to non-licensed place and without the help needed daily. On 02/03/2022 at 04:35 p.m., during an interview, Resident 1 stated he choose to leave the facility and wanted to stay in a house independently as he used to live before being in the facility. Resident 1 stated at first, he had a helper who assisted him and another one who did the cooking and cleaning but both left. Resident 1 stated he could not cook for himself or take care of his personal care because he was blind. Resident 1 stated ILO dropped him at GACH 1 and since then, never heard from him. The facility failed to safely discharge Resident 1, who was blind and needed staff assistance with all activities of daily living (ADLs, such as personal hygiene, bathing, dressing, etc.). On 7/21/2021, Resident 1 was discharged to an independent living home (unlicensed independent living home). As a result, Resident 1 was taken to General Acute Care Hospital 1 (GACH 1) by the owner of the home. The above violation had a direct relationship to the health, safety, and security of Resident 1.