Health inspection·November 7, 2024

F624 42 CFR §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 9/17/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint related to unsafe discharge. The facility (Skilled Nursing Facility 1 [SNF 1]) failed to protect Resident 1’s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) and failed to ensure a safe and orderly discharge was provided to Resident 1, who exhibited behaviors that made Resident 1 a danger to himself (Resident 1) and others, and who was admitted to SNF 1, a locked facility (facility that cares for residents that utilize secured perimeter fences or locked exit doors) to SNF 2, a non-locked facility (a facility that does not have secured or locked units) on 9/4/2024 without providing safe and orderly discharge services by: 1. Failing to ensure Registered Nurse 2 (RN 2) obtained a physician order from Medical Doctor 1 (MD 1- Resident 1’s attending physician) to discharge Resident 1 to SNF 2 on 9/4/2024. 2. Failing to ensure that the facility staff at SNF 1 provided SNF 2 with the discharge summary and recapitulation of stay (a summary of a resident course of treatment and stay at a facility) for Resident 1 when Resident 1 was discharged to SNF 2 on 9/4/2024. SNF 2 was only provided the Order Summary Report (a list of the physician orders for a resident, while the resident was admitted to a facility). 3. Failing to ensure facility staff from SNF 1 conducted a hand off communication (the transfer of resident medical information from the licensed nurse of the discharging facility to the licensed nurse of the receiving facility for continuity of care) to SNF 2 in preparation of receiving and admitting Resident 1 on 9/4/2024. 4. Failing to ensure facility staff established or specified the specific care that Resident 1 needed that SNF 1, a locked unit was unable to provide, that required Resident 1 to be discharged to SNF 2, an unlocked and less secure unit. 5. Failing to ensure the facility staff at SNF 1 utilized medical transport when discharging Resident 1 to SNF 2 on 9/4/2024, after the facility identified that Resident 1 was a danger to self and to others. As a result, Resident 1 was discharged from SNF 1 to SNF 2 on 9/4/2024 using a non-medical transport after Resident 1 was identified as being a danger to himself (Resident 1) and to others; and placed Resident 1 at increased risk for injury, medication errors, and worsening of unresolved medical conditions. 1. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 9/1/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD- a common lung disease that causes breathing problems by restricting airflow), type two (2) diabetes mellitus (a long-term medical condition in which the body has trouble controlling blood sugar and using it for energy), schizoaffective (a mental illness that can affect a person’s thoughts, mood and behavior) disorder and psychosis (a severe mental condition in which thought and emotions are affected that contact is lost with external reality). A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/4/2024, indicated that Resident 1 had memory problems and difficulty in making decisions regarding tasks of daily life. A review of Resident 1’s Admission Summary dated 9/1/2024 timed at 4:00 p.m. indicated Resident 1 was incontinent (unable to voluntarily control the excretion of urine or the contents of the bowels) of bladder (a sac- shaped muscular organ that stores urine) and bowel (a long, tube-shaped organ in the abdomen that is part of the digestive system) function, had unsteady gait (pattern of walking), was confused (refers to the inability to think clearly or quickly), and agitated (a condition in which a person is unable to relax and be still) towards others. The Admission Summary further indicated that Resident 1 had a preference of sitting and crawling on the floor requiring one to one (1:1- where a staff member is assigned to monitor the resident at all times) supervision. A review of Resident 1’s Physician Discharge Summary dated 9/4/2024 indicated Resident 1’s discharge was necessary for the health and safety of individuals in the facility that would be endangered due to Resident 1’s clinical (medical) or behavioral status. A review of Resident 1’s Notice of Transfer/Discharge, with a notification date of 9/4/2024 and effective date of 9/4/2024, indicated that the notice was to inform Resident1 that the discharge to SNF 2 was necessary for the safety of individuals in the facility that would be endangered due to Resident 1’s clinical or behavioral status. A review of Resident 1`s Physician`s Order dated 9/4/2024, timed at 2:20 p.m., indicated that MD 1 provided a verbal order to discharge Resident 1 to SNF 2. The Physician’s Order was documented by RN 2 and signed by MD 1. A review of Resident 1’s Recapitulation of Stay dated 9/4/2024, timed at 5:00 p.m. indicated Resident 1’s reason for discharge to SNF 2 was because of behavior (not specified). Resident 1’s Recapitulation of Stay indicated Resident 1 needed skilled care and nursing services and required assistance with physical functioning such as bathing, bed mobility, dressing, toilet use, locomotion (ability to move from one place to another) and walking. A review of Resident 1’s Health Status Note dated 9/4/2024 timed at 5:10 p.m. indicated Resident 1 was discharged to SNF 2 via a non-medical transport. A review of Resident 1’s SNF 2 Record of Death, dated 9/5/2024, the Record of Death indicated that Resident 1 expired in SNF 2 on 9/5/2024 at 3:30 a.m. During a concurrent interview and record review on 9/18/2024 at 11:30 a.m. with RN 2, Resident 1’s Physician’s Order dated 9/4/2024, timed at 2:20 p.m. that indicated that MD 1 gave a verbal order to discharge Resident 1 to SNF 2 and was documented by RN 2 was reviewed. RN 2 stated that on 9/4/2024, RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1’s discharge, either in person or by phone before inputting the order to discharge Resident 1 to SNF 2. RN 2 stated that RN 2 entered the physician order to discharged Resident 1 to SNF 2 on 9/4/2024 and indicated that the order was received verbally by MD 1 because RN 2 was told by Social Service Director (SSD) that Resident 1 needed a physician order for discharge. RN 2 stated that when the SSD informs the licensed nurses of the facility that a resident is to be discharged, a licensed nurse will enter a verbal order for discharged into the resident’s physician order record on behalf of the physician. During a concurrent interview and record review on 9/18/2024 at 11:50 a.m. with MD 1, MD 1 reviewed Resident 1’s Physician’s Order dated 9/4/2024 to discharge Resident 1 to SNF 2. MD 1 stated that MD 1 was not in the facility on 9/4/2024. When MD 1 was asked how come MD 1 signed the physician order to discharge Resident 1 to SNF 2 on 9/4/2024 when RN 2 had stated that RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1’s discharge, either in person or by phone, MD 1 stated that “this is what is normally done in the facility”. MD 1 further stated that Resident 1’s physician order to discharge to SNF 2 dated 9/4/2024 did not include the reason for the discharge. During an interview with RN 2 on 9/24/2024 at 4:02 p.m., RN 2 stated that only physicians, nurse practitioners and physician assistant can give an order to discharge a resident. RN 2 stated that on 9/4/2024, RN 2 should have, but did not communicate with MD 1 concerning Resident 1’s discharge. RN 2 stated that by entering the order to discharge Resident 1 to SNF 2 on 9/4/2024, RN 2 deprived Resident 1 of a safe discharge to SNF 2, which is required for a safe and orderly discharge. During a concurrent interview and record review on 9/24/2024 at 4:07 p.m. with the Director of Nursing (DON), Resident 1’s Physician’s Order dated 9/4/2024, timed at 2:20 p.m. that indicated that MD 1 gave a verbal order to discharge Resident 1 to SNF 2 and was documented by RN 2 was reviewed. The DON stated that RN 2’s actions of entering the order to discharge Resident 1 to SNF 2 on 9/4/2024 without communicating to MD 1 was neglectful and the RN 2 should have acted based on her scope of practice. 2. During an interview with Registered Nurse 4 (RN 4) on 9/19/2024 at 3:12 p.m., RN 4 stated RN 4 worked at SNF 2. RN 4 stated that on 9/4/2024 at approximately 6:40 p.m. Resident 1 arrived at SNF 2 with only a summary of Resident 1’s Physician Orders dated 9/4/2024 from SNF 1. RN 4 stated that RN 4 attempted to call SNF 1 several times to attempt to speak with a licensed nurse from SNF 1 and obtain additional discharge information. RN 4 stated SNF 1 did not answer the phone. RN 4 stated that RN 4 had no prior knowledge that Resident 1 would be arriving to be admitted into SNF 2. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 9/19/2024 at 4:15 p.m., LVN 3 stated that LVN 3 works at SNF 2. LVN 3 stated that on 9/4/2024, Resident 1 had suddenly arrived at SNF 2. LVN 3 stated that LVN 3 had no prior knowledge that Resident 1 was arriving to SNF 2 for admission. LVN 3 stated that Resident 1 arrived with no Discharge Summary, and Recapitulation of Stay from SNF 1. LVN 3 stated that Resident 1 arrived with only Resident 1’s Physician Order Summary Report (totaling to four pages) from SNF 1. During an interview with RN 2 on 9/24/2024 at 4:02 p.m., RN 2 stated that on 9/4/2024, the only discharge paperwork that RN 2 completed for Resident 1 was writing Resident 1’s physician order for discharge. RN 2 stated that RN 2 endorsed Resident 1’s discharge to the oncoming shift nurse, Registered Nurse 3 (RN 3). RN 2 stated that RN 3 was to finish Resident 1’s discharge on 9/4/2024. During a concurrent interview and record review on 9/24/2024 at 4:21 p.m. with Medical Records Director 1 (MRD 1), Resident 1’s discharge forms, clinical and discharge documentations from 9/1/2024 to 9/4/2024 were reviewed. MRD 1 stated that there was no documented evidence found that a Discharge Care Plan, and a Medication Reconciliation (process of identifying the most accurate list of all medications that the resident is taking) form was completed, and copies of the Discharge Summary and Recapitulation of Stay from SNF 1 were sent with Resident 1 to SNF 2. During an interview with the DON on 9/24/2024 at 4:24 p.m., the DON stated that there was no documented evidence found that copies of Resident 1’s Discharge Summary and Recapitulation of Stay from SNF 1 were sent with Resident 1 to SNF 2. The DON stated that this was a neglectful deficient practice because the Discharge Summary and Recapitulation of Stay for Resident 1 should have been provided to Resident 1 as part of the safe and orderly discharge services. During an interview with RN 3 on 9/25/2024 at 5:03 p.m., RN 3 stated that on 9/4/2024 RN 3 completed Resident 1’s discharge packet which included Resident 1’s Discharge Summary and Recapitulation of Stay. RN 3 stated that RN 3 did not fax the discharge packet of Resident 1 to SNF 2. During a follow-up interview with MRD 1 on 9/25/2024 at 5:58 p.m., MRD 1 stated that the nursing staff involved in Resident 1’s discharge on 9/4/2024, that included RN 3, should have but did not send Resident 1’s discharge documentation including a Discharge Summary, a Recapitulation of Stay to SNF 2. 3. During an interview with RN 2 on 9/24/2024 at 4:02 p.m., RN 2 stated that RN 2 did not, by phone, in person, or in writing, communicate with any staff from SNF 2 of Resident 1’s discharge on 9/4/2024. During an interview with the DON on 9/24/2024 at 4:17 p.m., the DON stated that to the DON’s best knowledge, no nursing staff from SNF 1 gave a hand off communication report to a licensed nurse at SNF 2 as part of safe and orderly discharge services. The DON stated that this was a neglectful deficient practice because the nursing staff from SNF 1 should have conducted a hand off communication report to the licensed nurses at SNF 2. The DON stated that SNF 2 should be informed of the most current and pertinent nursing and medical information concerning Resident 1 in order to provide the necessary care and services to Resident 1. During an interview with the DON on 9/25/2024 at 4:00 p.m., the DON stated that licensed nurses of SNF 1 did not follow the facility’s policy and procedure for a safe and orderly discharge, when on 9/4/2024, the facility staff of SNF 1 did not provide a hand off communication regarding Resident 1’s pertinent nursing and medical information to SNF 2. During an interview with RN 3 on 9/25/2024 at 5:03 p.m., RN 3 stated that RN 3 did not give a hand off communication report to any staff at SNF 2. During an interview with MRD 1 on 9/25/2024 at 5:38 p.m., MRD 1 stated that no nursing staff from SNF 1 documented in Resident 1’s medical record that a hand off communication was conducted with SNF 2 regarding Resident 1’s discharge on 9/4/2024. 4. A review of the facility’s Facility Assessment Data Collection Tool, dated 2/2024 through 7/2024, indicated that the facility had admitted and treated other residents with psychosis and other mental disorders, impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life). The facility’s Facility Assessment Data Collection Tool further indicated that the facility had admitted and treated residents in need of “behavioral support, behavioral healthcare needs…. dementia care…and other mental disorders. During a concurrent interview and record review on 9/24/2024 at 3:20 p.m. with the DON, the facility’s Facility Assessment Data Collection Tool dated 2/2024 through 7/2024 was reviewed. The DON stated that the facility was capable of and had been providing care for residents with same diagnoses and behavior that Resident 1 had. The DON stated she was not aware of any services that Resident 1 needed that the facility could not provide that SNF 2 could provide other than that SNF 2 was not a locked facility. A review of Resident 1’s Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Conference Notes, dated 9/3/2024, indicated the facility’s IDT met to discuss Resident 1’s condition as of 9/3/2024, two days after the facility admitted Resident 1 from General Acute Care Hospital 2 (GACH 2) on 9/1/2024. The document indicated the IDT specifically discussed Resident 1’s fall incidents, Resident 1’s nutritional status and weight, Resident 1’s need for reminders to participate in group activities and a one to one staff assignment to “ensure resident is safe.” The document also indicated, “Unable to determine discharge plan at this time.” A review of Resident 1’s Health Status Note, dated 9/2/2024, 2:43 p.m., the health status note indicated that Resident 1 was unsteady on his feet and needed a one-to-one supervision (a nurse or health care support worker who provides care to a single resident for a period of time) to ensure his (Resident 1) safety related to falls prevention. A review of Resident 1’s care plan dated 9/1/2024 indicated that Resident 1 was at risk for wandering (a resident’s ai