Health inspection·April 9, 2025

F622  42 CFR §483.15(c) Transfer and discharge  §483.15(c)(1) Facility requirements-  i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless—  (A) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility;  (B) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility;  (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;  (D) The health of individuals in the facility would otherwise be endangered;  (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or  (F) The facility ceases to operate.  §483.15(c)(2) Documentation.  When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider.  (i) Documentation in the resident’s medical record must include:  (A) The basis for the transfer per paragraph (c)(1)(i) of this section.  (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).  (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by—  (A) The resident’s physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and  (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.  (iii)Information provided to the receiving provider must include a minimum of the following:  (A) Contact information of the practitioner responsible for the care of the resident.  (B) Resident representative information including contact information  (C) Advance Directive information  (D) All special instructions or precautions for ongoing care, as appropriate.  (E) Comprehensive care plan goals;  (F) All other necessary information, including a copy of the resident’s discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.       § 72521.        Administrative Policies and Procedures.  (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or  licensee.   (c) Each facility shall establish at least the following:  1. Personnel policies and procedures which shall include:    (A) Written job descriptions detailing qualifications, duties and limitations of each classification of employee available to all personnel.        (B) Employee orientation to facility, job, patient population, policies, procedures and staff.  (C) Staff Development.  (D)Employee benefits.  (E) Employee health and grooming.  1. Verification of licensure, credentials and references.

F842 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. § 72543. Patients' Health Records. (b). Information contained in the health records shall be confidential and shall be disclosed only to authorized persons in accordance with federal, state and local laws.   On 2/20/2025 at 9:25 AM, an unannounced visit was conducted by California Department of Public Health (CDPH) at the facility to investigate a complaint administration.   The facility failed to provide a safe and orderly discharge for Resident 1, upon transfer to the General Acute Care Hospital (GACH) Emergency room (ER) by failing to:   1. Ensure actual resident medical records that included appropriate information such as name of resident’s physician, contact information, Advance Directive (a legal document that provides guidance on a person’s preferences for medical treatment), and all other necessary information were provided to the GACH.  2. Ensure proper procedures and preparation necessary were carried out, such as providing resident ‘s medical history and ensuring identity was clearly communicated upon transfer to the GACH.   As a result of the above violations, Resident 1 was transferred to the GACH with another resident’s medical records and the GACH could not immediately identify Resident 1, delaying care and services.      A review of Resident 1’s “Admission Record”, indicated the resident was initially admitted to the facility on 1/24/2025 with a diagnosis of, but not limited to, influenza (contagious respiratory illness caused by influenza viruses) and Dementia (a group of symptoms that affect memory, thinking, behavior, and the ability to perform everyday activities).   A review of Resident 1’s “History and Physical Progress note” dated 1/27/2025, indicated Resident 1 lacks capacity to make medical decisions (unable to understand, evaluate, or make informed decisions about their healthcare due to a mental or cognitive impairment) and has memory loss.   A review of Resident 1’s “Minimum Data Set (MDS – a federally mandated resident assessment tool)”, Dated 2/8/2025, indicated the resident had severe cognitive impairment (has significant difficulty with memory, orientation, and judgment with inability to communicate effectively). The MDS also indicated the resident needed substantial/ Maximal assistance (requiring more than half the effort) for toileting, showering, dressing and all personal hygiene.   A review of Resident 1’s “Change of Condition Evaluation” Dated 2/16/2025, indicated the resident had a change of condition. Resident 1’s pertinent diagnosis was checked as having dementia (a group of symptoms that affect memory, thinking, behavior, and the ability to perform everyday activities) and was transferred 911 with a blood pressure of 84/61 and a heart rate of 130 at 4:59PM. Further indicating the resident had a decreased level of consciousness (sleepy, lethargic) prior to transfer to Acute Medical Hospital.   A review of Resident 1’s” Nursing progress notes”, dated 2/16/2025 indicated resident was transferred to Acute Medical hospital for septic work up (a series of tests and procedures performed to evaluate and diagnose sepsis, determine its source, and guide treatment), further indicating that the Medical Doctor was made aware, and that resident was self-responsible with no family on record.   A review of “Medical Doctor Telephone order”, dated 2/16/2025 indicated transfer to Emergency Department 911 for evaluation and management of tachycardia (elevated heartrate).   A review of “Discharge Summary” dated 2/16/2025, indicated resident welfare and needs cannot be met in the facility and need for transfer was indicated to further evaluation and provide treatment.   A review of “Transfer Form V4.1” dated 2/16/2025 At 5:34PM, indicated Resident 1 was transferred to Acute Medical Center for tachycardia (heart rate over 100 beats per minute), lethargy (extreme tiredness, fatigue or lack of energy) and hypotension (Low blood pressure) for Emergency Department to determine diagnoses and provide treatment.   A review of the facility’s Fax Transmission Verification Report, dated 2/16/2025 time at 8:50 PM, indicated Resident 1’s Admission Record was sent to the GACH, after Resident 1 was transferred at 5:34 PM. During an interview on 2/18/2025 at 8:00PM with Acute Hospital Emergency Room Case Manager, stated when she arrived at work around 6 PM on 2/16/2025, hospital staff were attempting to obtain medical records for Resident1. The Case Manager stated the resident who had been transferred to the GACH did not match the records sent with him. The Case Manager stated when calling to request Resident 1’s medical records, she was told by Registered Nurse 1 (RN1) to transfer resident 1 back to the facility and they would transfer the resident again with the correct records, since the medical records sent to the GACH belonged to Resident 2.   During an interview on 2/20/2025 at 10:15AM with Director of Nursing (DON), the DON stated when transferring a resident, the RN supervisor who is responsible for insuring the correct medical records and documentation transfer with the Resident. The DON stated the incident had the potential to delay treatment or even provide correct care was administered.     A review of the facility’s policy and procedure titled “Record Content / Transfer Record” dated 11/2017, indicated A transfer record that is complete and accurate with resident information in sufficient detail to provide for continuity of care shall be transferred with the resident at the time of the transfer to another health care facility. Further indicating transfer to another health care facility shall include the following records, resident identifying information, resident representative, physician name and telephone number, diagnosis at time of transfer, reason for transfer, admission face sheet, physician’s orders, History and physical, laboratory results, Advance Directive, Medication and treatment records. * Note: it is critical to ensure the current Medication and treatment records are complete if these are copied and sent in the transfer packet to the acute hospital.     A review of the facility’s policy and procedure titled “Transfer or Discharge, Facility – Initiated” dated October 2022, indicated facility – initiated transfers and discharges, when necessary, must meet specific criteria and require resident/ representative notification and orientation, and documentation as specified in this policy. Further indicating Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.       The facility failed to provide a safe and orderly discharge for Resident 1, upon transfer to the GACH ER by failing to:   1.Ensure actual resident medical records that included appropriate information such as name of resident’s physician, contact information, Advance Directive, and all other necessary information were provided to the GACH.  2. Ensure proper procedures and preparation necessary were carried out, such as providing resident ‘s medical history and ensuring identity was clearly communicated upon transfer to the GACH.   As a result of the above violations, Resident 1 was transferred to the GACH with another resident’s medical records. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.