Health inspection·November 18, 2024

F625 Notice of Bed Hold Policy Before/Upon Transfer §483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies— (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility’s policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e)(1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

F626 Permitting Patients to Return to Facility   §483.15(e)(1) Permitting Patients to return to facility.   A facility must establish and follow a written policy on permitting Patients 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. (ii) If the facility that determines that a Patient who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.   §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a Patient returns is a composite distinct part (as defined in § 483.5), the Patient must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the Patient must be given the option to return to that location upon the first availability of a bed there.  On 10/29/20204, at 8:13 AM an unannounced visit was made by the California Department of Public Health [CDPH] at the facility to investigate a complaint regarding transfer and discharge. As a result, CDPH determined, the facility failed to ensure Patient 1 who was transferred to a General Acute Care Hospital (GACH) via 911 emergency services for a change in condition, was provided written information regarding the facility’s bed-hold policies and permitted to be readmitted back to the facility on the first available bed, in accordance with the facility’s policy and procedure titled “Bed-Holds and Return,” and the “California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities” for one of three sampled Patients (Patient 1).  Patient 1, who was transferred to the GACH from Skilled Nursing Facility (SNF) 1 on 10/17/2024 due to a change in condition and was medically stable to be discharged back to SNF 1 on 10/22/2024, had to stay in the GACH setting for six additional days (from 10/22/24 to 10/28/24) when Patient 1 was transferred and admitted to SNF 2 due to SNF 1 refusing to readmit Patient 1 back.     This deficient practice had the potential to cause psychosocial harm to patient 1 and incurred unnecessary hospital days (6 days) at the GACH, from 10/22/2024 to 10/28/2024.    A review of Patient 1’s Admission Record indicated a 58 year old, female patient, admitted to SNF 1 on 3/01/2024 and readmitted on 7/24/2024 with diagnoses including metabolic encephalopathy (an brain disorder caused by a chemical imbalance in the blood that affects brain function), unspecified psychosis not due to a substance or known psychological condition (a condition that cause a person to lose touch with reality , making it difficult to distinguish what is real and what is not) , Type 2 diabetes (high blood sugar).  A review of Patient 1's History and Physical (H&P) dated 3/4/2024, the H&P indicated Patient 1 does not have capacity to understand and make decision.  A review of Patient 1's Minimum Data Set (MDS, a federally mandated Patient assessment tool) dated 9/03/2024, the MDS indicated Patient 1’s cognition (thought process) was moderately impaired.   A review of Patient 1’s Change of Condition (COC) dated 10/17/2024, the COC indicated Patient 1 was transferred by SNF 1 to the GACH at 6:50 PM via 911 emergency services due to altered mental status (AMS).  A review of a facility document titled “Daily Census Recap,” dated 10/17/2024, the Daily Census Recap indicated Patient 1 was discharged to the GACH timed at 7:36 PM. The Daily Census Recap indicated in Patient 1’s status “Return not anticipated.”  A review of a facility document titled “Daily Census Recap,” dated 10/18/2024 to 10/28/2024, Patient 1’s name did not indicate the resident’s status was not placed on the “bed hold” list.  A review of the GACH record provided by the facility titled “Final Report,” dated 10/25/2024 and timed at 9:10 AM, the GACH record indicated “Patient [1] is able to go back to her facility [SNF 1] when bed is available after medically cleared.”  During an interview on 10/29/2024 at 9:02 AM, SNF 1’s Registered Nurse (RN 1) stated, when Patient 1 was transferred to the GACH, Patient 1 was not placed on a seven-day bed hold and facility staff did not notified the resident’s family.  During a telephone interview on 10/29/2024 at 9:30 AM, GACH Social Service Director (SSD) 1 stated she was the assigned SSD and works at the GACH where Patient 1 was admitted from SNF 1. GACH SSD 1 stated Patient 1 was admitted to the GACH on 10/17/2024 due to AMS. GACH SSD 1 stated that on 10/22/2024, she called SNF 1 and spoke with the Administrator (ADM) inform the ADM that Patient 1 was ready to be readmitted back to SNF 1. The ADM stated Patient 1 was aggressive and an elopement risk (the potential danger that a patient or Patient may leave a healthcare facility without authorization, which could put their health or safety at risk) and requiting a locked facility (a facility secured with locked doors to prevent Patients from exiting the premises at will). During the same interview on 10/29/2024 at 9:30 AM, the ADM informed GACH SSD 1 that Patient 1 was not appropriate to return back to SNF 1. GACH SSD 1 stated the ADM requested Patient 1’s psychiatric evaluation and clearance and GACH SSD 1 was able to provide the clearance to SNF 1 on 10/24/2024. GACH SSD 1 stated she called the ADM on 10/24/2024 and informed the ADM that Patient 1 was stable and on adjusted psychotropic medications. GACH SSD 1 stated Patient 1 was appropriate to return back to the facility. GACH SSD 1 stated that on 10/25/24, she called back the ADM to follow up on Patient 1’s readmission to SNF 1, however, the ADM stated Patient 1 was not placed on bed hold, since SNF 1 did not want to take Patient 1 back. GACH SSD 1 stated Patient 1 was transferred to another facility [SNF 2] on 10/28/2024, since SNF 1 delayed the resident’s GACH discharge and readmission back to a SNF.  During an interview on 10/29/2024 at 10:04 AM, SNF 1’s SSD [SSD 2] stated that Patient 1 was exhibiting aggressive behavior and was at risk for elopement. SSD 2 stated when Patient 1 was transferred to the GACH on 10/17/2024, the ADM asked the GACH’s assistance to help find a placement for Patient 1. SSD 2 further stated that it was the facility’s [SNF 1] responsibility to find appropriate placements for its own Patients.  During an interview and record review of Patient 1's active care plans and IDTs, on 10/29/2024 at 11:42 AM, SNF 1’s Director of Nursing (DON) stated that according to the facility’s policy, when a Patient is transferred to the GACH, the Patients are placed on a seven-day bed hold. However, the DON stated that the ADM instructed the DON not to place Patient 1 on bed hold when the Patient was transferred to the GACH, because the ADM believed Patient 1 required a higher level of care and the GACH can help SNF 1 find placement. The DON clarified that there was no prior IDT meeting or discharge care planning involving Patient 1 that included the resident’s family [FAM 1] to discuss the need for another level of care, prior to 10/17/2024. The DON stated, because Patient 1 was not placed on bed hold, the facility did not notify FAM 1 about the seven-day bed hold.  During an interview on 10/29/2024 at 12:16 AM, SNF 1’s Licensed Vocational Nurse (LVN 1) stated that he transferred Patient 1 to the GACH on 10/17/2024 and did not place Patient 1 on bed hold or provided the family [FAM 1] with written information regarding the facility and state bed-hold policies.  During an interview on 10/29/2024 at 12:30 AM, FAM 1 stated that the facility did not inform her or provided her with written information regarding the facility and the state bed-hold policies upon Patient 1’s transfer to the GACH on 10/17/2024. FAM 1 stated they preferred for Patient 1 to be readmitted back to SNF 1 but was told by GACH SSD 1 that SNF 1 did not want to readmit Patient 1 back.  During an interview on 10/29/2024 at 12:39 PM, the ADM stated that Patient 1 was aggressive and at high risk for elopement. The ADM stated that when Patient 1 was transferred to the GACH on 10/17/2024, the transfer “presented an opportunity to collaborate with the GACH in finding a placement for the resident.” The ADM stated that he did not place Patient 1 on a bed hold status on 10/17/2024 because, according to state and federal regulations, the facility would be obligated to readmit the Patient if the Patient was placed on bed hold. The ADM further stated that on 10/22/2024, he received a call from SSD 1 at the GACH and was informed that Patient 1 was ready to return to the facility [SNF 1]. The ADM stated he requested both psychiatric and medical clearances and received the documents on 10/24/2024 but believed that additional paperwork was needed to confirm that Patient 1 was fully cleared. The ADM stated that it was the responsibility of the DON to confirm the resident’s medical clearance for return. The ADM also stated that no IDT meeting or care planning had been conducted prior to Patient 1's transfer to GACH on 10/17/2024 to assess the need for a locked facility or a higher level of care.   A review of a facility document titled “California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities” signed by FAM 1 and a Representative of SNF 1 dated 3/4/2024, the document indicated, “Bed Holds and Readmission: If you must be transferred to an acute hospital for seven days or less, we will notify you or your or representative that we are willing to hold your bed. You or your representative has 24 hours after receiving this notice to let us know whether you want us to hold your bed for you. If Medi-Cal is paying for your care, then Medi-Cal will pay for up to seven days for us to hold the bed for you. If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulations Sections 72520(c) and 73504(c)) to offer you the next available appropriate bed in our Facility. You should also note that, if our Facility participates in Medi-Cal and you are eligible for Medical, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted.”  A review of the facility’s policy and procedure (P&P) titled “Bed-Holds and Return,” revised October 2022, indicated “All Patients/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Patients, regardless of payer source, are provided written notice about these policies at least twice: notice I: well in advance of any transfer (e.g., in the admission packet); and notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours Reissuance of notice I must occur if either the bed-hold policy under the state plan or facility policy changes after the notice is issued. Multiple attempts to provide the Patient representative with notice 2 should be documented in cases where staff were unable to reach and notify the representative timely. The written bed-hold notices provided to the Patients/representatives explain in detail the duration of the state bed-hold policy, if any, during which the Patient is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid Patients); the facility policy regarding bed-hold periods , the facility per-diem rate required to hold a bed (for non-Medicaid Patients), or to hold a bed beyond the state bed-hold period (for Medicaid Patients); and e. t