Other·May 31, 2024

§483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility’s discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and— (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident’s or caregiver’s/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident’s goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident’s comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident’s goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident’s needs, and include in the clinical record, the evaluation of the resident’s discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident’s representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident’s discharge or transfer. §483.70(p) Social worker. Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is: §483.70(p)(1) An individual with a minimum of a bachelor’s degree in social work or a bachelor’s degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and §483.70(p)(2) One year of supervised social work experience in a health care setting working directly with individuals. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 3/9/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about quality of care. The facility failed to have a discharge planning process (process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge) for Resident 1. The facility failed to: 1. Develop a Discharge Care Plan for Resident 1 since admission to the facility. 2. Ensure regular re-evaluations of Resident 1 to identify changes that require modification of the discharge plans. 3. Discuss, make referrals, and document in the clinical record when Resident 1 manifested interest in returning to the community. 4. Complete on a timely basis an evaluation of Resident 1's discharge needs and discharge plan, and with Resident 1 discuss and document all relevant information in Resident 1's clinical record. 5. Ensure the facility, which has more than 120 beds, had a qualified social worker to evaluate and address Resident 1’s social services-related needs. As a result, Resident 1 eloped (left the health care facility unsupervised and undetected) from the facility after a second attempt, which resulted in Resident 1 sustaining a fracture (break of a bone) on 12/23/2023. Two days later, on 12/25/2023, Resident 1 was admitted at a General Acute Care Hospital 1 (GACH 1) where she was identified with a displaced comminuted fracture (the bone is broken in two or more pieces and moves so that the two ends are not lined up straight) of the left distal femur (lower part of the thigh bone near the knee). A review of Resident 1's Admission Record indicated the facility originally admitted the 54-year-old female resident on 1/21/2021, with diagnoses including schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion [a false belief or judgment against what is real]), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and arthritis (pain and swelling causing decreased function on the joints). The Admission Record also indicated Resident 1 was admitted for short-term, was self-responsible, and was a transient (homeless). A review of Resident 1's Care Plan developed on 10/21/2021, for Resident 1's risk for fracture, indicated as a goal to minimize Resident 1's risk for fracture and injury. The interventions included providing Resident 1 with a safe and hazard-free environment, assisting Resident 1 with all transfers and ambulation (walking) as needed, and implementing useful interventions per assessment. A review of Resident 1's Care Plan developed on 2/21/2022, for Resident 1's elopement risk, had a goal for Resident 1 not leaving the premises/safe area unauthorized, with target date of 4/11/2024. The interventions included monitoring at frequent intervals and providing one-to-one (one staff supervising the resident always) if indicated to redirect behavior. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/13/2023, indicated the resident had moderate impaired cognition ability (to comprehend, think, solve problem, process information, and make decisions). A review of Resident 1's Social Services (SS) interdisciplinary team (IDT, group of health professionals from different disciplines that participate in the care of a resident) Discharge Planning form, with an effective date of 10/13/2023, and signed by Social Services Assistant 2 (SSA 2) on 11/10/2023, indicated Resident 1 needed long term care without discharge potential, had family support, level of care was adequate, and Resident 1 preferred not to talk about returning to the community. A review of Resident 1's History and Physical exam, completed by the attending physician and dated 11/24/2023, indicated Resident 1 had mild impaired cognition. A review of Resident 1's Change of Condition (COC)/Interact Assessment Form, dated 11/29/2023, indicated that at 9 a.m. and at 11 a.m., Resident 1 was in bed talking to herself and refused medications and nursing care. At 1 p.m., Resident 1 had increased confabulation (a type of memory error in which gaps in a person's memory are filled with fabricated, misinterpreted, or distorted information; imagined and real memories are confused), aggression toward staff, and was trying to leave the facility. A staff chased after Resident 1 and returned her to the facility. At 1:30 p.m., Resident 1 continued trying to leave the facility. The attending physician was informed and ordered to transfer Resident 1 to a hospital for evaluation due to increased agitations and delusions and aggression (having violent behavior towards others). A review of Resident 1's unsigned Description of a Concern/Grievance/Theft Loss form, dated 11/29/2023, indicated Resident 1 stated, "I want to leave this facility and you guys don't let me leave." The form indicated Resident 1 said she would not tell where she was going and to just let her leave. Resident 1 also told the social services staff (unable to determine who wrote the note) that "I am well capable of taking care of myself," and "I just don't want to be here anymore." A review of Resident 1's Licensed Nursing Note, dated 11/30/2023, indicated Resident 1 returned from the hospital and was readmitted to the facility. A review of Resident 1's Physical Therapy (PT) Evaluation, dated 11/30/2023, indicated the reason for referral was the recent hospitalization. The evaluation indicated Resident 1 appeared functioning at baseline and was very active/mobile within the facility using the wheelchair. Resident 1 was independent with transfers, standing, bed mobility, and was moving in the hallways in her wheelchair. PT intervention was not necessary. A review of Resident 1's COC/Interact Assessment Form, dated 12/23/2023, indicated that at 4:19 p.m., Licensed Vocational Nurse 3 (LVN 3) was informed that Resident 1 was missing. Police was called at 4:41 p.m. and arrived at the facility at 4:45 p.m. The facility did not have a picture of Resident 1 due to her refusal to allow staff to take her picture. A description of Resident 1 was provided to the police. The COC form indicated Resident 1 did not have money, was non-compliant (not willing to cooperate with treatment or refusing of care offered) with care, was confused, and was verbally aggressive at times. A review of the Concern Report form, dated 12/23/2023, indicated Resident 1 was seen by Resident 2 and visitors leaving the facility in her wheelchair. The form indicated Resident 1 was able to make decisions, did not tell staff she was leaving, did not have family, was self-responsible, was able to make decisions, and was non-compliant with care. The police were called to help find Resident 1 because she had limited mobility, did not have money, and it was cold. A review of Resident 1's Leaving Against Medical Advice form (AMA, patient's decision to leave the facility having been informed of and appreciating the risks of leaving without completing treatment), dated 12/23/2023, indicated Resident 1 left the facility AMA and did not sign the AMA form. The AMA form also indicated the police was notified. A review of an untitled document dated 12/27/2023 and signed by the Director of Nursing (DON), indicated police found Resident 1 at GACH 1 on 12/26/2023. The note indicated Resident 1 did not wish to return to the facility. A review of Resident 1's GACH 1 Emergency Documentation, dated 12/25/2023, indicated Resident 1 was admitted on 12/25/2023. Resident 1's X-ray (a type of radiation exam used to produce images of internal body parts) results showed Resident 1 had a displaced comminuted fracture of the left distal femur. On 3/15/2024, at 12:55 p.m., during an interview, Resident 2 stated she witnessed Resident 1 leaving the facility. Resident 2 stated she observed Resident 1 in the wheelchair using the feet to push and propel the wheelchair backwards up the driveway incline. Resident 2 stated Resident 1 was wearing only a shirt with no sweater or jacket. Resident 2 stated she told a staff member (unable to remember the name of the staff member) that Resident 1 went out of the facility. On 3/15/2024, at 3:23 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated during the time Resident 1 left the facility, the outside temperatures had been between 40 degrees Fahrenheit (°F - unit of measuring temperature) to 55 degrees °F during the night. LVN 1 indicated Resident 1 would be exposed to extreme cold, rain, or frost. LVN 1 indicated that Resident 1 would not have access to food or water, and ultimately might be harmed from assault by another person, or even die. LVN 1 stated Resident 1 did not want to be in the facility. On 3/15/2024, at 5:04 p.m., during an interview, Registered Nurse 1 (RN 1) stated Resident 1 was always angry and non-compliant with care. On 3/20/2024, at 12:50 p.m., during an interview and concurrent review of Resident 1's clinical record, SSA 1 stated that the role of Social Services is to be in-charge of discharge planning, to be able to answer any questions or concerns that residents may have, to advocate (to provide support or recommendations) for the residents if they need anything, to assist in finding placement, or to help with home health or home care if needed. SSA 1 stated that discharge planning starts upon a resident's admission to the facility, and this would include discussing the prior living situation and any goal to return home after being cleared by the attending physician. SSA 1 stated there was no documentation that the physician addressed Resident 1's discharge from the facility and the type of living arrangement Resident 1 needed post-discharge. SSA 1 stated Resident 1 did not want to stay at the facility but did not have family or a place to go to. SSA 1 stated there was no documented discharge plan discussed with Resident 1 and there should have been a meeting to ensure Resident 1 had a safe discharge. SSA 1 stated there was no Social Worker in the facility. SSA 1 stated that on 11/29/2023, Resident 1 had increased delusions and was trying to leave the facility. SSA 1 stated that Resident 1 would have benefited from discharge planning to discuss what Resident 1's goals or future goals were and if Resident 1 refused to have discharge planning, then that should have been documented. On 3/20/2024, at 2:33 p.m., during an interview with SSA 2 and a concurrent review of Resident 1's clinical record, SSA 2 stated Resident 1 did not have documented discharge planning since Resident 1's admission on 1/21/2021 and there was no discharge planning discussed with Resident 1 after Resident 1's initial attempt to leave the facility on 11/29/2023. SSA 2 stated that Resident 1's discharge from the facility was not a planned discharge and was not a safe discharge. SSA 2 indicated that Resident 1 is exposed to the risks of falling, having no food available, or having nowhere to sleep. SSA 2 stated it is scary to be out in the streets. On 3/20/2024, at 4 p.m., during an interview and review of Resident 1's clinical records, the Director of Nurses (DON) stated that on Resident 1's first attempt to elope from facility on 11/29/2023, a Psychiatry (branch of medicine who study mental illness) or Psychology (study of mind and behavior) evaluation should have been provided, but nothing was offered. The DON indicated that Resident 1 was readmitted to the facility on 11/30/2023, and eloped for the second time on 12/23/2023, but there were no attempts to speak with Resident 1 about discharge planning between those dates. On 4/16/2024, at 1:18 p.m., during an interview and record review, the DON stated that Resident 1 did not have a discharge care plan created since originally being admitted to the facility on 1/21/2021. On 4/17/2024, at 12:25 p.m., during an interview with LVN 6 and concurrent review of Resident 1's progress notes dated 7/24/2023 and timed at 3:03 p.m., LVN 6 stated a police officer came to visit