Health inspection·December 19, 2024

42 CFR §483.15 Admission, Transfer, and Discharge §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. 22 CFR § 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 CFR § 72433 Social Work Service Unit – Services (b) Social work services unit shall include but not be limited to the following: (b)(5)Discharge planning for each patient and implementation of the plan. On 11/3/2024 the California Department of Public Health (CDPH) received a complaint indicating Resident 1 was discharged home from the facility without home health services (a type of medical care that provides skilled services in a patient's home to treat or manage an illness). On 11/5/2024 at 8:00 AM, the CDPH conducted an unannounced visit at the facility to investigate the complaint allegation. The facility failed to: 1. Ensure home health services were arranged and provided for Resident 1, who lived alone and required extensive assistance with activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). 2. Educate Resident 2, who was diagnosed with chronic obstructive pulmonary disease (COPD- chronic lung disease causing difficulty in breathing), on the use of continuous oxygen therapy (a treatment that provides you with extra oxygen to breathe in) before discharging the resident home. 3. To assess Resident 2’s personal portable oxygen tank (brought in from home) to ensure it was functioning and could provide continuous oxygen therapy per physician orders before discharging the resident home. 4. Follow its policy and procedure (P &P) titled, “Discharge Summary and Plan,” which indicated every resident was evaluated for his or her discharge needs and an individualized post-discharge plan developed to assist the resident with discharge. 5. Follow up to ensure Residents 1 and 2, were comfortably settled at home post discharge. As a result, Resident 1 was confined at home in her wheelchair from 11/1/2024 through 11/6/2024, resulting in a maceration (skin condition that occurs when skin is exposed to moisture for an extended period) on her buttocks and perineum (tiny patch of sensitive skin between the genitals) from sitting in her stool and urine. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 and diagnosed with bilateral lower extremity venous stasis rash (a skin condition where blood pools in the lower legs due to poor circulation causing the skin to become swollen, itchy, discolored, dry, cracked, and inflamed). It also placed Resident 2 at risk for low oxygen levels, respiratory distress, and death. A) Resident was a 79-year-old female admitted to the facility on 9/9/2024, with diagnoses including generalized muscle weakness, heart attack (life-threatening emergency where blood flow to the heart is blocked), chronic embolism and thrombosis (a condition where blood clots form in a vein, usually in the legs, potentially breaking off and traveling to the lungs) of the right lower extremity. A review of Resident 1’s History and Physical (H&P), dated 9/10/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s discharge Minimum Data Set (MDS, a resident assessment tool required by the federal government), dated 11/1/2024, indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 required set-up and/or clean-up assistance for brushing her teeth, upper body dressing, and personal hygiene, and required supervision or touch assistance for toileting hygiene, showering or bathing, and lower body dressing. The MDS indicated Resident 1 required partial to moderate assistance to move 50 feet and 150 feet while in a manual wheelchair. The MDS also indicated Resident 1 was frequently incontinent (inability to control) of bowel and bladder function. A review of Resident 1’s physician orders, dated 10/30/2024, indicated to discharge Resident 1 home with home health services by the Home Health Agency (HHA 1). A review of Resident 1’s Discharge Summary, dated 11/1/2024, indicated on 11/1/2024 Resident 1 was discharged from the facility with home health services through HHA 1. The Discharge Summary indicated Resident 1 required extensive assistance for ADLs and mobility. The Discharge Summary indicated Resident 1’s skin was intact at the time of discharge. A review of an email correspondence between HHA 1 and the Social Services Director (SSD), dated 11/5/2024, indicated the SSD scanned the referral documents on 10/30/2024 at 1:11 PM and sent the referral to HHA 1 on 11/5/2024 at 1:47 PM, 6 days later. During an interview on 11/5/2024 at 9:30 AM, with Resident 1, Resident 1 stated she was confined to her wheelchair in the entryway of her apartment since she was discharged home from the facility on 11/1/2024. Resident 1 stated she slept in the wheelchair, and urinated and had bowel movements in the incontinence brief worn the day she was discharged from the facility. Resident 1 stated she could not get to the bathroom. Resident 1 stated when she contacted the HHA 1 at the number provided by the SSD, the HHA 1 informed her they did not receive orders for her to receive home health services from the agency. Resident 1 stated she felt frustrated. During an interview on 11/5/2024 at 10:19 AM, with the Case Manager (CM) 1 from HHA 1, the CM 1 stated she never spoke with anyone from the facility regarding Resident 1, and the HHA 1 never received any referrals or faxes from the facility regarding Resident 1’s discharge and HHA services. During an interview on 11/5/2024 at 12:30 PM, with the Family Friend (FF 1), the FF 1 stated Resident 1 did not bathe or sleep and had urinated and had bowel movements in her wheelchair, since being discharged home because she was unable to get up on her own. FF 1 stated she was not a designated caregiver for Resident 1 and could not provide consistent the assistance Resident 1 needed. During an interview on 11/5/2024 at 4:59 PM, with Resident 1, Resident 1 stated she was suffering from severe pain in her left leg, extending from her knee to her ankle. Resident 1 stated she was supposed to elevate her legs, but she could not elevate them while in the wheelchair. During an interview on 11/6/2024 at 8:45 AM, with the CM from HHA 1, the CM 1 stated she received a referral via email from the facility’s SSD, around 2:00 PM on 11/5/2024, for Resident 1 to receive home health services. CM 1 stated Resident 1’s, the physician order for discharge and referral for home health services was dated 10/30/3024. CM 1 stated home health services were not provided due to the delayed receipt of the referral. During a concurrent interview and record review, on 11/6/2024 at 9:47 AM, with the SSD, Resident 1’s Discharge Summary dated 11/1/2024, was reviewed. The SSD stated the Discharge Summary, indicated Resident 1 was discharged home on 11/1/2024 and was supposed to receive home health services through HHA 1. The SSD stated she did not confirm HHA 1 would be providing services prior to discharging Resident 1 on 11/1/2024. The SSD stated it was important for residents to have confirmed arrangements for home health services prior to discharge to ensure the residents received the care needed once they left the facility. The SSD stated it was not safe to discharge Resident 1 without ensuring home health services would be provided, as ordered by the physician. The SSD stated Resident 1 required assistance with her ADLs and mobility. The SSD stated she did not follow up to ensure Resident 1 was comfortably settled at home and receiving home health services. The SSD stated without home health services, Resident 1 was at risk for injuries related to falls and skin breakdown due to her inability to care for herself. During a concurrent interview and record review, on 11/6/2024 at 10:11 AM, with Licensed Vocational Nurse (LVN) 1, Resident 1’s Discharge Summary, dated 11/1/2024, was reviewed. LVN 1 stated Resident 1’s Discharge Summary indicated Resident 1 required extensive assistance with ADLs and could not stand up or walk by herself. LVN 1 stated the Discharge Summary indicated Resident 1 was incontinent of bowel and bladder and her skin was intact at the time of discharge. LVN 1 stated it was not safe for Resident 1 to be discharged home without someone available to help her, or arrangements for home health services. LVN 1 stated Resident 1 was at risk for injury, skin breakdown and urinary tract infection (UTI, an infection in the bladder/urinary tract) from her incontinence and inability to perform hygiene tasks on her own, hospitalization, and death. A review of Resident 1’s GACH 1 record, dated 11/6/2024, the record indicated Resident 1 was brought to the emergency department on 11/6/2024 with complaints of severe lower extremity pain and injury. The record indicated Resident 2 was diagnosed with bilateral lower extremity venous stasis rash and the emergency department physician recommended hospitalization for further evaluation and management. B) Resident 2 was an 83-year-old female admitted on 6/19/2024, with diagnoses including, but were not limited to, chronic obstructive pulmonary disease (COPD, chronic lung disease causing difficulty in breathing), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently). A review of Resident 2’s MDS, dated 10/18/2024, indicated Resident 2 had moderate cognitive impairment. The MDS indicated Resident 2 required supervision and/or touching assistance for picking up small objects. A review of Resident 2’s physician’s order, dated 10/4/2024, indicated Resident 2 was to be discharged home with HHA 3. A review of Resident 2’s physician orders, dated 10/18/2024, indicated continuous oxygen therapy for desaturation (when blood oxygen levels drop below normal) related to her COPD diagnosis. A review of Resident 2’s care plan titled, “Altered Respiratory Status/Difficulty Breathing related to COPD”, dated 7/9/2024, indicated staff will administer oxygen therapy as ordered to prevent complications related to difficulty breathing or poor oxygen absorption. A review of Resident 2’s Discharge Summary, dated 10/18/2024 indicated Resident 2 required oxygen equipment after her discharge from the facility. The Discharge Summary did not indicate any instructions were provided to Resident 2 at the time of discharge related to the use of continuous oxygen therapy. During an interview on 11/5/2024 at 1:01 PM, with FF 2, FF 2 stated on 10/18/2024, he assisted Resident 2 with her discharge from the facility. FF 2 stated the facility did not provide any instructions on how much oxygen Resident 2 required, or whether the oxygen therapy was needed continuously. During a concurrent interview and record review, on 11/6/2024 at 1:41 PM, with LVN 1, Resident 2’s IDT Conference Note dated 10/18/2024, was reviewed. LVN 1 stated the IDT Conference Note did not indicate Resident 2 or FF 2 were provided any teaching related to the resident’s orders for continuous oxygen therapy. LVN 1 stated the IDT Conference Note did not indicate that Resident 2’s personal portable oxygen delivery device was checked by facility’s staff to ensure it was able to provide continuous oxygen as ordered. LVN 1 stated Resident 2 was at risk for difficulty breathing, desaturation, hospitalization, and death from not receiving teaching related to oxygen administration, and assessment of her portable oxygen delivery device, to ensure it worked and could meet the resident’s needs. A review of the SSD job description dated 3/2017, indicated the SSD would assist in discharge planning with appropriate agencies, entities, or individuals to include agency services, equipment, and agency referrals. The JD indicated the SSD will coordinate with the IDT team. A review of the facility’s P&P titled, “Discharge Summary and Plan,” dated 10/2022, indicated the facility will ensure the post-discharge plan included arrangements for follow-up care and services. The P&P indicated the resident, or his/her representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. The facility failed to: 1. Ensure home health services were arranged and provided for Resident 1, who lived alone and required extensive assistance with activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). 2. Educate Resident 2, who was diagnosed with chronic obstructive pulmonary disease (COPD- chronic lung disease causing difficulty in breathing), on the use of continuous oxygen therapy (a treatment that provides you with extra oxygen to breathe in) before discharging the resident home. 3. To assess Resident 2’s personal portable oxygen tank (brought in from home) to ensure it was functioning and could provide continuous oxygen therapy per physician orders before discharging the resident home. 4. Follow its policy and procedure (P &P) titled, “Discharge Summary and Plan,” which indicated every resident was evaluated for his or her discharge needs and an individualized post-discharge plan developed to assist the resident with discharge. 5. Follow up to ensure Residents 1 and 2, were comfortably settled at home post discharge. As a result, Resident 1 was confined at home in her wheelchair from 11/1/2024 through 11/6/2024, resulting in a maceration (skin condition that occurs when skin is exposed to moisture for an extended period) on her buttocks and perineum (tiny patch of sensitive skin between the genitals) from sitting in her stool and urine. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 and diagnosed with bilateral lower extremity venous stasis rash (a skin condition where blood pools in the lower legs due to poor circulation causing the skin to become swollen, itchy, discolored, dry, cracked, and inflamed). It also placed Resident 2 at risk for low oxygen levels, respiratory distress, and death. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.