Other·November 14, 2023

42CFR §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. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when— (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). 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. 42 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. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. 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. 22 CCR § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 10/17/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about refusal to readmit a resident. The facility failed to implement its policies and procedures (P&Ps) on Transfers, Beholds and Discharges and Resident Rights for Resident 1’s, who was unable to understand and make decisions and was dependent on staff for all activities of daily living (ADLs, such as bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene) when on 9/14/2023, the facility transferred Resident 1 to General Acute Care Hospital 1 (GACH 1) for evaluation and treatment. The facility failed to: 1. Provide Resident 1 and the resident’s representative a written notification of discharge, the reason, and the location to which the resident was being discharged. 2. Provide Resident 1 with a safe and orderly discharge. 3. Allow Resident 1 to return to the facility from GACH 1. As a result, Resident 1’s right to return to the facility was violated, the resident was discharged against the wishes of the resident’s representative, without a determined facility, and without the due process. A review of Resident 1’s Admission Record indicated the facility admitted the 91-year old female on 6/10/2023 with diagnoses including encephalopathy (damage or disease affecting the brain), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), Parkinson’s disease (brain disorder causing uncontrolled movements such as shaking or difficulty with balance), dysphagia (having difficulty in swallowing), and gastrostomy tube (GT, a surgically inserted tube from outside of abdomen directly into the stomach to administer nutrition and medications). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 6/14/2023, indicated the resident had severely impaired cognition (thought process, remembering names and details, problem solving, and decision-making tasks). The MDS indicated Resident 1 required extensive assist from staff with all activities of daily living (ADLs, such as bed mobility, transferring, toilet use, and personal hygiene). A review of a 30-day Notice of the Discharge addressed to Resident 1 and Resident 1's representative, signed by the Administrator in Training (AIT) and dated 9/7/2023 indicated the facility decided to transfer / discharge Resident 1. The 30-day Notice of the Discharge on or before 10/7/2023 indicated the form was provided to Resident 1 and her representative. The effective date of transfer or discharge was on before 10/7/2023. Resident 1 would be discharged home with hospice, a Board and Care (B&C, a lower level of care residential home that provides non-medical care to residents) with Hospice Care (care for patients during end of life) or a long-term care facility of the resident’s choice/ or assigned by facility if none is selected. The specific discharge location to which Resident 1 would be discharged and the reason for the discharge was not indicated. A review of Resident 1 Physician’s Order, dated 9/14/2023, indicated to transfer Resident 1 to GACH 1 for GT re-insertion. A review of the Notice of Resident Transfer or Discharge, dated 9/14/2023, indicated Resident 1 was transferred to GACH 1. The reason for the transfer indicated, “the transfer or discharge is/was necessary for the resident’s welfare and the resident’s needs cannot/could not be met in the facility.” A review of Resident 1’s GACH 1 History and Physical (H&P) dated 9/15/2023, indicated the resident came to the emergency room with a dislodged GT that was replaced and sent back to the facility. On 10/18/2023 at 1:50 p.m., during interview, Registered Nurse 1 (RN 1) stated that if a resident needed assistance with ADLs and had a GT, it would be difficult to receive such care if not readmitted. On 10/18/2023 at 5:50 p.m., during interview, the Admission Coordinator (AC) stated that on 9/14/2023, the same day Resident 1 was sent out, GACH 1 sent Resident 1 back to the facility, but another resident was already admitted in Resident 1’s bed. The AC stated the bed was made available for a new admission as payment for Resident 1’s bed hold was not provided by the family. The AC stated that Resident 1 was not readmitted and was sent back to GACH 1 the same day. On 11/7/2023 at 11:35 a.m., during a concurrent interview and record review with the Business Office Manager (BOM), Resident 1’s medical records were reviewed. The BOM stated that on 9/7/2023, Resident 1’s family was provided with a Notice of Transfer or Discharge form for the resident to be discharged home with hospice, a B&C facility, or another long-term care facility of family choice. The BOM stated the notice of transfer or discharge form did not include names of facilities to which Resident 1 would be discharged. On 11/7/2023 at 11:48 a.m., during an interview, the Social Worker (SW) stated that the notice for transfer and discharge given to Resident 1’s representative on 9/14/2023 did not include the name of the facility the resident would be discharged to. The SW indicated that when Resident 1 was transferred to GACH 1 for treatment, it was only for the hospitalization not a discharge with no readmission. The SW stated Resident 1’s discharge was involuntary and not by choice because the resident and her representative did not want the resident to leave the facility. On 11/7/2023 at 12:10 p.m., during an interview and concurrent record review with Licensed Vocational Nurse 1 (LVN 1), Resident 1’s medical record was reviewed. LVN 1 stated that a therapeutic leave is when a resident needs to leave the facility for a day or days for medical appointments including hospitalization to GACH if it meets the resident’s wellbeing and health needs. LVN 1 stated that on 9/14/2023, Resident 1 was transferred to GACH for GT re-insertion and returned on the same day in the evening. LVN 1 stated Resident 1 was not readmitted and was sent back to GACH 1 on 9/14/2023. LVN 1 stated that on 9/15/2023, GACH 1 made a second attempt to return Resident 1 back to the facility but Resident 1’s bed was already occupied by another resident. A review of the facility policy titled, “Transfers/Beholds and Discharges – Out of Facility,” with effective date 1/2023, indicated the facility shall not transfer, discharge or seek to evict a resident solely as a result of a change in financial payer or type; the facility shall give a resident/responsible party adequate notice of any transfer or discharge; when the facility transfers or discharges a resident under any of the circumstances specified in the Notice of Proposed Transfer/Discharge form, the facility will 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 provided; the facility will develop a discharge planning procedure for each resident that focuses on the resident's discharge goals, the preparation of the residents to be active partners and effectively transition them to post-discharge care in order to reduce factors leading to preventable readmissions; the SSD and licensed nurse will document the discharge destination of the resident, including name, address and telephone number; the SSD will indicate the information on the Notice of Proposed Transfer/Discharge and provide a copy to the Ombudsman and /or responsible party. A review of the facility policy titled, “Resident Rights,” dated 1/2023 indicated the resident has the right to be informed of his or her right and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility and the facility staff shall treat all residents with kindness, respect, and dignity. The facility failed to implement its P&Ps on Transfers, Beholds and Discharges and Resident Rights for Resident 1’s, who was unable to understand and make decisions and was dependent on staff for all ADLs when on 9/14/2023, the facility transferred Resident 1 to GACH 1 for evaluation and treatment. The facility failed to: 1. Provide Resident 1 and the resident’s representative a written notification of discharge, the reason, and the location to which the resident was being discharged. 2. Provide Resident 1 with a safe and orderly discharge. 3. Allow Resident 1 to return to the facility from GACH 1. As a result, Resident 1’s right to return to the facility was violated, the resident was discharged against the wishes of the resident’s representative, without a determined facility, and without the due process. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.