Health inspection·May 19, 2025

§483.15 Notice of bed-hold policy and return (d)(1) Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies: (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any. (iii) The nursing facility's policies regarding bed-hold periods. (d)(2) At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section. 22 CCR § 72520- Bed Hold (a)If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. 22 CCR § 72323- 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 4/15/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) did not receive the required 7-day bed hold. On 4/16/2025, the CDPH conducted an unannounced visit to the facility to investigate the complaint. The facility failed to: 1. Ensure Resident 1 and Resident 3’s assigned beds were available upon their return to the facility. 2. Follow its policy and procedure (P&P) titled, "Bed-Holds and Returns", which indicated prior to a transfer, written information will be given to the residents and/or the resident representative that explains in detail the rights and limitations of the resident regarding bed holds. As a result, Resident 1 and Resident 3’s rights were violated. A. Resident 1 was an 81-year-old male, admitted to the facility on 2/3/2025 and readmitted on 4/14/2025 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (HTN- high blood pressure), and obesity (condition of having excess body weight). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/7/2025, indicated Resident 1's cognition (ability to reason and understand) was severely impaired. The MDS indicated Resident 1 needed moderate (helper provides less than half the effort) assistance with showering, dressing, and performing personal hygiene. A review of Resident 1's Bed Hold Informed Consent (document notifying a resident of their right to a seven-day bed hold), indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) on 4/6/2025. During an interview on 4/16/2025 at 10:40 a.m. with the Business Office Manager (BOM), The BOM stated Resident 1's bed should have been held from 4/6/2025 to 4/13/2025. The BOM stated Resident 1's bed was assigned to another resident on 4/7/2025, one day after Resident 1 was transferred to the GACH. The BOM stated the seven-day bed hold was not honored. The BOM stated, residents have the right to have their bed held because it gives them the opportunity to come back to the facility. The BOM stated, "Coming back to a different room would hurt because it’ s your home." The BOM stated she did not know why Resident 1’s bed was not held. During an interview on 4/16/2025 at 12:47 p.m., the Social Services Director (SSD) stated when a resident was transferred to the GACH, the facility would hold their bed for seven days to ensure they have a bed available upon return. The SSD stated if a resident returned to a new room from the GACH, the resident would not feel comfortable. The SSD stated she did not know why Resident 1's bed was given away on 4/7/2025. B. Resident 3 was a 73-year-old male, admitted to the facility on 9/3/2024 with diagnoses including schizoaffective disorder, hypertension, and Diabetes ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 3's MDS, dated 3/12/2025 indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 needed moderate assistance with showering, dressing, and performing personal hygiene. A review of Resident 3's Situation, Background, Assessment, Recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 4/3/2025, indicated Resident 3 was transferred to the GACH on 4/3/2025. During an interview on 4/16/2025 at 10:40 a.m. with the BOM, The BOM stated Resident 3's bed should have been held from 4/3/2025 to 4/10/2024. The BOM stated Resident 3's bed was not available when he was readmitted on 4/7/2025. The BOM stated Resident 3 was placed in the bed that was on hold for Resident 1. The BOM stated she did not know what happened to Resident 3's previous bed. During a concurrent interview and record review on 4/16/2024 at 3:04 p.m. with the Director of Nursing (DON), Resident 3's Bed Hold Informed Consent form, dated 1/10/2025, was reviewed. The DON stated the Bed Hold informed consent was not completed prior to Resident 3’s transfer to the GACH. The DON stated the consent form was supposed to be signed upon admission and at the time of transfer, so the residents were aware of their rights concerning the seven-day bed hold. The DON stated if the Bed Hold form was not completed, the residents or, the responsible party would not be aware. The DON stated the seven-day bed hold was automatic for everyone, and did not need to be requested. The DON stated it was important to keep the same bed because the residents were used to their room. The DON stated she does not know why the consent form was not completed. The DON does not know why the bed was not held. A review of the facility's P&P titled, "Bed-Holds and Returns," dated March 2017, indicated prior to a transfer, written information would be given to the residents and/or the resident representatives that explains in detail the rights and limitations of the resident regarding bed holds. During a review of the facility's P&P titled, "Resident Rights" dated December 2016, the P&P indicated residents have the right to be informed about his or her rights and responsibilities. The facility failed to: 1. Ensure Resident 1 and Resident 3’s assigned beds were available upon their return to the facility. 2. Follow its policy and procedure (P&P) titled, "Bed-Holds and Returns", which indicated prior to a transfer, written information will be given to the residents and/or the resident representative that explains in detail the rights and limitations of the resident regarding bed holds. As a result, Resident 1 and Resident 3’s rights were violated. These violations had a direct relationship with the security of Resident 1, Resident 3 and all residents.