Health inspection·August 13, 2024

§483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless— (A) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident’s medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by— (A) The resident’s physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident’s discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must— (i) Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. 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 6/14/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about an allegation the facility inappropriately discharged Resident 1. The facility failed to safely discharge Resident 1, who was intellectually disabled (a condition that limits intelligence and disrupts abilities necessary for living independently) and with history of schizophrenia (mental illness that affects how a person thinks, feels, and behaves) and bipolar disease (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) by: 1. Failing to ensure Resident 1 was discharged to a setting that would meet the resident’s needs on 5/30/2024. 2. Failing to provide an Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) Care Conference (an opportunity to review the on-going work with the resident and allow the resident, their family, and/or responsible party to voice opinions and concerns, and to involve them with plans of care) for resident, family, and responsible party to address plan of discharge and participate in discharge planning process as indicated in Resident 1’s Care Plan on Discharge dated 3/11/2024. 3. Failing to inform Resident 1’s conservator (someone who is court-appointed with legal responsibility for another person's affairs when the person is unable to care for themselves) of Resident 1’s discharge on 5/30/2024 as indicated in facility’s policy and procedure (PnP) titled, "Resident Initiated Transfer or Discharge" dated 3/2022. 4. Failing to inform the receiving Board and Care (B&C - a residential care option catering to individuals requiring assistance with daily living activities) about Resident 1’s physician and pharmacy contact information as indicated in facility’s PnP titled, "Resident Initiated Transfer or Discharge" dated 3/2022. As a result, Resident 1 was placed at risk for unsafe discharge to an unlicensed board and care. During a review of Resident 1’s Admission Record indicated the facility admitted the 61-year old male resident on 11/25/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation (sudden worsening of symptoms that lasts for several days), epilepsy (brain disorder that causes recurring, unprovoked seizures [sudden, uncontrolled body movements and changes in behavior]), unspecified (unconfirmed) intellectual disabilities, and unspecified schizophrenia. During a review of Resident 1’s Preadmission Screening and Resident Review (PASSR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 3/11/2024, indicated the resident was Level 1 positive (resident is suspected of mental illness or intellectual or developmental disability) and required Level II mental health evaluation (to confirm that an individual has a mental illness or intellectual disability. The Level II evaluation also assesses the residents need for nursing facility services and whether the resident requires specialized services or specialized rehabilitative services). During a review of Resident 1’s History and Physical, dated 3/18/2024, indicated the Resident 1 had capacity to make decisions. During a review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/15/2024, indicated the resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 needed supervision or touching assistant with oral hygiene, toileting, and shower. 1. During a review of Resident 1’s Order Summary Report, dated 4/25/2024, indicated an order to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) emergency room for evaluation and treatment related to suicidal ideation (thoughts or feelings of wanting to hurt or kill oneself). During a review of Resident 1’s GACH 1’s Emergency Documentation, dated 4/25/2024, indicated the resident was brought in by Emergency Medical System (EMS-also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) from the facility due to suicidal ideation with plan to cut Resident 1’s neck with a cord. During a review of the facility’s Census List, dated 6/18/2024, indicated Resident 1 was readmitted to the facility on 4/26/2024. During a review of Resident 1’s Progress Notes, dated 5/25/2024, indicated at 5:30 p.m., the resident reported to Licensed Vocational Nurse 5 (LVN 5) that the resident requested to go to a psychiatric ward (sometimes called mental health ward or behavioral health ward, places designed to provide intense care for psychiatric patients whose needs cannot be adequately met in a current setting) and if not taken, Resident 1 will kill Resident 4. During a review of Resident 1’s Order Summary Report, dated 5/25/2024, indicated physician’s order to transfer the resident out to GACH for homicidal (having tendencies toward the killing of another person) attempt. During a review of Resident 1’s GACH 1’s Emergency Documentation, dated 5/25/2024, Indicated the resident was brought in by EMS from the facility with chief complaint of homicidal ideation (thoughts or feelings of wanting to hurt or kill another person). During a review of the facility’s Census List, dated 6/18/2024, indicated Resident 1 was readmitted to the facility on 5/26/2024. During a review of Resident 1’s Change in Condition (COC) Evaluation, dated 5/29/2024, indicated the resident was transferred to GACH 1 per Resident 1’s request to go to GACH 1 Emergency Room for Psychiatrist (doctor who specializes in mental health) evaluation. The COC indicated Resident 1 had physical aggression (behavior causing or threatening physical harm towards others) and verbal aggression (the use of words or gestures to cause psychological harm). The COC indicated Resident 1 verbalized wanting to kill Social Service Assistant (SSA) and attempted to leave the facility. The COC indicated Physician 1 was notified and ordered to transfer Resident 1 to GACH 2. The COC indicated Resident 1’s Representative (RR 1) was called with "no answer". During a review of Resident 1’s Progress Notes, dated 5/29/2024 at 6:59 p.m., indicated that at 5:30 p.m., Resident 1 was heard yelling inside the resident’s room. LVN 1 and the Social Services Director (SSD) went to Resident 1’s room and heard Resident 1 wanted to kill himself (Resident 1) and the SSA. The Progress Notes indicated Resident 1 planned on hitting his own head on the wall until he (Resident 1) dies. Resident 1 then started hitting the right side of his head with open hand and when LVN 1 attempted to intercept (stop), Resident 1 made a fist toward LVN 1. The Progress Notes indicated Resident 1 exited (left) the facility while staff followed him; Resident 1 was voicing his want to go to psychiatric hospital (a place for people in need of treatment for severe mental disorders). The Progress Notes indicated 911 (an emergency number for any police, fire, or paramedics [medical professionals who assess a patient's condition and administer emergency medical care and may transport patients to medical facilities]) was called at 6:15 p.m. The Progress Notes indicated family (the name was not indicated) was notified. During a review of Resident 1’s late entry (documentation which is not made as soon as possible after an event has occurred) Progress Notes, dated 5/29/2024, indicated firefighters came and assessed Resident 1 in the lobby and escorted Resident 1 to GACH 1 for safety concern. During a review of Resident 1’s Care Plan on transfer to GACH 1, dated 5/29/2024, indicated Resident 1 required transfer due to change in behavior unable to be managed by the facility. During a review of Resident 1’s Progress Notes, dated 5/30/2024 at 2:08 p.m., indicated the resident was readmitted to the facility. During a review of Resident 1’s late entry Progress Note for 5/30/2024, indicated the resident had history of multiple behavioral concerns that involve safety between nearby residents and facility staff and had been transferred to a psychiatric hospital on multiple times. The Progress Notes indicated higher management (Administrator [ADM]) had approved for Resident 1 to be discharged to a board and care (B&C) with the Placement Agency’s (PA - organization that assist in locating facilities/setting for discharge) help due to the endangerment of the facility staff and nearby residents. The Progress note indicated family (the name was not indicated) and the County Regional Center (CRC - organization that coordinates and provides community-based services to persons with intellectual and developmental disabilities) were notified regarding the urgency of the discharge plan. During a review of Resident 1’s Progress Notes, dated 5/30/2024 at 7:37 p.m., indicated Resident 1 was discharged to the B&C (there is no specific name of the B&C) with the PA’s assistance. During a review of Resident 1’s Progress Notes, dated 5/31/2024 at 5 p.m., indicated Regional Social Service 1 (RSS 1) called and spoke to SSD and SSD informed RSS 1 that the facility was not equipped or specialized with intellectual needs or disabilities or had the psychiatric component that can manage Resident 1’s behavior. The Progress Notes indicated the facility does not have the proper resources to meet Resident 1's needs in stabilizing behaviors resulting to Resident 1’s multiple outbursts and altercations (argument or fight) that the facility felt unsafe. During a review of Resident 1’s GACH 1’s Emergency Documentation, dated 6/7/2024, indicated Resident 1 was admitted to GACH 1 on 6/7/2024 brought in by the Board and Care Administrator (B&C ADM). The GACH 1’s Emergency Documentation indicated the B&C was no longer able to care for Resident 1 and that Resident 1 was aggressive and combative to staff and other residents. The GACH 1’s Emergency Documentation also indicated Resident 1 verbalized killing everyone in the B&C if returned. The GACH 1’s Emergency Documentation indicated Resident 1 was seen by psychiatric services and deemed appropriate for inpatient admission for 5150 (a person in mental health crisis can be detained for 72 hours for evaluation in a psychiatric facility). During an interview, on 6/13/2024 at 4:50 p.m., RSS 1 stated Resident 1 was discharged to an unlicensed B&C. RSS 1 stated it was an unsafe placement. RSS 1 stated that during the week of 6/3/2024, Resident 1 was taken to GACH 3 and GACH 1, both of which returned the resident to the B&C. RSS 1 stated on 6/7/2024, Resident 1 was admitted to GACH 1. During an interview, on 6/14/2024 at 9:51 a.m., SSA stated Resident 1 initiated the discharge. SSA stated Resident 1 would go to the Social Services office asking to be discharged and SSA informed the resident that the CRC was looking for placement. SSA stated she was not sure if the B&C (where the resident was discharged last 5/30/2024) was licensed. SSA stated Resident 1 should be discharged as much as possible to a licensed B&C. During an interview, on 6/14/2024 at 10:13 a.m., the SSD stated the ADM informed the SSD to initiate Resident 1’s discharge for the safety of the residents in the facility. The SSD stated Resident 1 had consistent behavior of verbal outburst and asking daily to be discharged. The SSD informed Resident 1 that the CRC was looking for placement. The SSD stated it was hard to get hold of RSS 1. During an interview, on 6/18/2024 at 8:20 a.m., Placement Agent 1 (PA 1 - staff working at the Placement Agency) stated the facility informed the PA that the family was notified of Resident 1’s