Other·March 23, 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 12/28/2021, 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 provide Resident 1 a safe and orderly discharge by not ensuring oxygen was delivered home prior to the resident’s discharge. Resident 1, who was dependent on oxygen, was discharged home with one small oxygen tank and the Home Health Agency (HHA) taking over the resident's care, did not have oxygen at the resident's home. The oxygen run out and Resident 1 required emergency transfer to a general acute care hospital (GACH). As a result, Resident 1 was in respiratory distress requiring hospitalization the same day of discharge 12/17/2021. A review of Resident 1's Admission Record indicated the facility admitted the resident on 12/14/2020 with diagnoses including hypertensive high blood pressure heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure, acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), type 2 diabetes (s is an impairment in the way the body regulates and uses sugar [glucose] as a fuel), muscle weakness, and atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). A review of Resident 1's care plan on Discharge initiated on 12/3/2020, included in the interventions making arrangements with required community resources to support independence post-discharge. A review of the Physician's Order for Resident 1 dated 4/25/2021, indicated oxygen inhalation at two liters per minute via nasal canula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help; this device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) continuously. A review of Resident 1's care plan on Oxygen Therapy initiated on 4/26/2021, included in the interventions to provide the resident with oxygen via nasal prongs at two liters per minute continuously. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/23/2021, indicated Resident 1 was able to comprehend, remember and make decisions. Resident 1 required extensive assistance with staff with one-person physical assist with transfers, dressing, toilet use, and personal hygiene. Resident 1 required continued oxygen therapy. There was no active discharge planning occurring for the resident to return to the community. The section for for Return to the Community indicated it was unknown or uncertain. A review of Resident 1's Social Work Progress Notes dated 11/29/2021, indicated Resident 1 told the Social Services Designee (SSD) that she wanted to return home. SSD told Resident 1 he would assist her with her discharge home. A review of the Physician's Order for Resident 1, dated 12/15/2021, indicated to discharge the resident home on 12/16/2021 with home health: Registered Nurse (RN), Physical Therapy (PT), Occupational Therapy (OT), Durable Medical Equipment (DME): Hospital Bed and Oxygen. A review of Resident 1's Progress Notes dated 12/17/2021, indicated the resident was discharged and the Home Health Agency unable to provide the oxygen to the resident and was advised to call 911 (emergency number to get immediate assistance). During an interview and concurrent record review with Licensed Vocational Nurse 1 (LVN 1) on 12/28/2021 at 11:36 a.m., LVN 1 stated Resident 1 was discharged home on 12/17/2021. On the day of discharge LVN 1 instructed Resident 1's Certified Nursing Assistant (CNA) to give Resident 1 a small full tank of oxygen (e-tank, which last approximately five to six hours when used at two liters per minute) to go home with Resident 1. LVN 1 stated she did not check to make sure the oxygen tank sent home with Resident 1 was full. LVN 1 state LVN 1 did not know if there was oxygen at home prior to discharge. On 12/28/2021 at 12:00 p.m., during an interview and concurrent record review, Social Services Designee (SSD) stated oxygen was not delivered to Resident 1's home prior to discharge. SSD stated on 12/17/2021 SSD received a phone call from the HHA requesting a signature for Resident 1's oxygen order but the resident was already in need of oxygen and was advised to call 911 (emergency medical assistance). On 2/17/2022 at 11:40 a.m., during an interview and concurrent record review, Director of Nursing (DON) stated there was no documentation indicating Resident 1 was discharged home with a full tank of oxygen. Resident 1 should not have been discharged without verifying oxygen was delivered to the resident’s home. DON stated if we knew the oxygen was not going to be delivered then, "we would not have discharged the resident." During an interview on 2/17/2022 at 4:02 p.m. DON stated the facility did not have a policy specific to discharging a resident with medical equipment. A review of the facility's policy and procedures titled, "Transfer or Discharge Documentation," revised 12/2016, indicated when a resident is transferred or discharged, details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. A review of the facility's policy and procedures titled, "Discharge Summary and Plan," revised 12/2016, indicated the post-discharge plan will be developed by the Care Planning/Interdisciplinary Team (IDT) with the assistance of the resident and his or her family and will include: e. How the IDT will support the resident or representative in the transition to post-discharge care. The facility failed to provide Resident 1 a safe and orderly discharge by not ensuring oxygen was delivered home prior to the resident’s discharge. Resident 1, who was dependent on oxygen, was discharged home with one small oxygen tank and the HHA taking over the resident's care, did not have oxygen at the resident's home. The oxygen run out and Resident 1 required emergency transfer to a GACH. As a result, Resident 1 was in respiratory distress requiring hospitalization the same day of discharge 12/17/2021. The above violation had a direct relationship to the health, safety, and security of Resident 1.