Health inspection·January 3, 2025

CFR §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. (ii) If the facility that determines that a resident 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. On 11/13/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding Admission, Transfer, and Discharge Rights. The facility failed to permit Resident 1 to return to the facility after hospitalization. As a result, Resident 1 experienced an unnecessary prolonged hospitalization. A review of Resident 1’s Admission Record indicated the facility originally admitted the resident on 5/29/2024 with diagnoses that included intracranial (within the skull) injury with loss of consciousness (when a person is neither awake nor aware of the external environment) of unspecified duration, traumatic subdural (space between the skull and the brain) hemorrhage (excessive bleeding) with loss of consciousness of 30 minutes or less, and acute (sudden) respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). A review of Resident 1’s Minimum Data Set (MDS -a resident assessment tool), dated 6/5/2024 indicated that Resident 1 was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impaired and was dependent from staff for transfer, dressing, toilet use, personal hygiene, and bathing. A review of Resident 1’s Change of Condition (COC- a sudden clinically important deviation from a resident’s baseline in physical, cognitive, behavioral, or functional domains)/Interact Assessment Form dated 9/10/2024 indicated an order to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) due to abnormal Computed Tomography (CT- imaging test that produces images of the inside of the body) scan results. A review of Resident 1’s Order Summary Report indicated an order to transfer to GACH 1 for further evaluation and treatment secondary to abnormal CT scan results, dated 9/10/2024. A review of the facility’s census (daily list indicating resident names with corresponding room numbers) dated 11/16/2024 (census for 11/17/2024), 11/17/2024 (census for 11/18/2024), and 11/18/2024 (census for 11/19/2024), indicated that there was one available male bed (Room 325B) in the facility. A review of Resident 1’s GACH 1 physician’s progress note dated 11/17/2024 indicated that Resident 1’s repeat CT of the head on 10/27/2024 has improved and stable overall. The progress note indicated Resident 1 is now stable for discharge. A review of Resident 1’s GACH 1 Discharge Orders dated 11/19/2024 indicated a list of discharge medications to be continued upon Resident 1’s return to the facility. During an interview on 11/14/2024 at 3:15 p.m., with the Administrator (ADM), the ADM stated Resident 1 was admitted to the facility on 5/29/2024 to the facility’s subacute unit (medical care setting where residents require more complex, round-the-clock care). The ADM stated Resident 1’s health had improved and was transferred from the facility’s subacute unit to the facility’s skilled nursing unit (setting where residents need medical care or treatment that only a licensed nurse or other healthcare professional can provide) until Resident 1 was transferred to GACH 1 on 9/10/2024. The ADM stated Resident 1 had been discharged from the facility for more than 60 days from the facility’s skilled nursing unit and now returning to the facility’s subacute unit is considered a new resident in the facility’s subacute unit. The ADM stated he (ADM) understands that a resident whose hospitalization or therapeutic leave exceeds the bed hold period will return to the facility to the resident’s previous room if available or immediately upon the first available bed. The ADM stated since it has been more than 30 days since Resident 1 was transferred to the hospital and Resident 1 is returning to the facility’s subacute unit and not the facility’s skilled nursing unit, it is the facility’s discretion to prioritize the facility’s long-term subacute residents who have been discharged no more than 30 days to be fair. During an interview on 11/15/2024 at 3:45 p.m., with the ADM, the ADM stated it is only fair to prioritize to readmit the facility’s long-term subacute residents since Resident 1 was discharged from the facility’s skilled nursing unit and will be a new admit to the facility’s subacute unit. During an interview on 11/19/2024 at 9:40 a.m., with General Acute Care Hospital Case Manager 1 (GACH CM 1), GACH CM 1 stated Resident 1 had a discharge order for 11/17/2024 and the GACH physician consultants cleared Resident 1 to be transferred back to the facility’s subacute unit. GACH CM1 stated a bed request referral was sent to the facility on 11/18/2024 and was declined because there was no bed available. During an interview on 11/19/2024 at 10:10 a.m., with GACH CM 2, GACH CM 2 stated Resident 1 had a discharge order dated 11/17/2024. GACH CM 2 stated the facility’s Admission Director (AD), and the Director of Nursing (DON) stated the facility does not have an available subacute bed. During a concurrent interview and record review on 11/19/2024 at 3:35 p.m., with the AD, reviewed the facility’s bed request inquiries titled, “Care Services Requests,” the facility’s census dated 11/16/2024 (census for 11/17/2024), 11/17/2024 (census for 11/18/2024), and 11/18/2024 (census for 11/19/2024), and the facility’s policy and procedure titled, “Readmission to the Facility,” last reviewed on 7/16/2024. The AD confirmed by stating that an inquiry for Resident 1’s bed request was sent on 11/18/2024 at 8:55 a.m. by GACH CM 1 and on 11/19/2024 at 1:00 p.m. by GACH CM 3. The AD confirmed by stating that the facility’s census dated 11/16/2024, 11/17/2024, and 11/18/2024 indicated there was an available male bed (Room 325B) in the facility on 11/18/2024 and 11/19/2024. The AD stated the facility should have readmitted Resident 1 based on the facility’s “Readmission to the Facility” policy which indicated that residents who have been discharged to the hospital will be given priority in readmission to the facility upon the first availability of a bed. During a concurrent interview and record review on 11/19/2024 at 3:35 p.m., with the DON, reviewed the facility’s bed request inquiries titled, Care Services Requests,” the facility’s census dated 11/16/2024 (census for 11/17/2024), 11/17/2024 (census for 11/18/2024), and 11/18/2024 (census for 11/19/2024), and the facility’s policy and procedure titled, “Readmission to the Facility,” last reviewed on 7/16/2024. The DON confirmed by stating that an inquiry for Resident 1’s bed request was sent on 11/18/2024 at 8:55 a.m. by GACH CM 1 and on 11/19/2024 at 1:00 p.m. by GACH CM 3. The DON confirmed by stating that the facility’s census dated 11/16/2024, 11/17/2024, and 11/18/2024 indicated there was an available male bed (Room 325B) in the facility on 11/18/2024 and 11/19/2024. The DON stated the facility should have readmitted Resident 1 based on the facility’s “Readmission to the Facility” policy which indicated that residents who have been discharged to the hospital will be given priority in readmission to the facility upon the first availability of a bed. A review of the facility’s policy and procedure titled, “Readmission to the Facility,” last reviewed on 7/16/2024, indicated residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. A Medicaid resident (someone who receives health care coverage through the Medicaid program which is a public health care insurance program for people with limited incomes and resources) whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room. The facility failed to permit Resident 1 to return to the facility after hospitalization. As a result, Resident 1 experienced an unnecessary prolonged hospitalization. The above violations had a direct relationship to the health, safety, or security of Resident 1.