Health inspection·January 20, 2023

F661 §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. (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. §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over the counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. § 72433. Social Work Service Unit - Services. (b) Social work services unit shall include but not be limited to the following: (5) Discharge planning for each patient and implementation of the plan. § 72519. Patient Transfer. (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). § 72521. Administrative Policies and Procedures.  (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. § 72523. Patient Care Policies and Procedures. Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § 72547. Content of Health Records. A facility shall maintain for each patient a health record which shall include: (10) Discharge planning notes when applicable. (14) Condition and diagnoses of the patient at time of discharge or final disposition. (15) A copy of the transfer form when the patient is transferred to another health facility. On 11/4/2022 at 12:45 p.m., the Department received a complaint regarding a resident (Resident 1), who was unsafely discharged from the facility on 10/27/2022 to an unlicensed transitional living facility (facility that provides temporary housing and shelter for an extended period) that did not meet the needs of the resident. On 11/7/2022, the Department conducted an unannounced investigation at the facility. The facility failed to implement Resident 1’s discharge plan according to the facility’s policies and procedures, which indicated every resident would be evaluated for his or her discharge needs and would have an individualized post-discharge plan. The facility failed to: 1. Ensure Resident 1 was involved in his discharge planning process, and the resident’s discharge needs were evaluated and met. 2. Ensure a discharge plan was developed and the resident was instructed of his discharge medications including self-administering insulin (medication used to manage high blood sugar) and use of a blood glucose meter (device used to measure the blood sugar level in the body). 3. Follow up on Resident 1’s request to be discharged to his family member’s (FM 1) home. 4. Set up the home-health referral for medication management and safety. 5. Ensure Resident 1’s discharge forms were thoroughly completed including the “Post Discharge Plan of Care,” “Physician’s Discharge Summary,” and “Discharge Summary/Comprehensive Assessment.” As a result, Resident 1 was unsafely discharged to an unlicensed transitional living facility (UTLF), on 10/27/2022 ,which could not meet the resident's needs. Resident 1’s blood sugar was not monitored, and the resident did not receive insulin for two days which increased the resident's risk of developing high or low blood sugar levels. Resident 1 was discharged to UTLF 1 without any care givers (a person who provides direct care to another) and was sent to UTLF 2 after 20 minutes because UTLF 1 could not meet Resident 1's needs. After two days, Resident 1 was transferred to a general acute care hospital (GACH) with complaints of chest and abdominal pain and lack of a safe discharge location. During a review of Resident 1’s Admission Record (face sheet), the face sheet indicated Resident 1 was a 64 year old male, was originally admitted to the facility on 12/29/2021 and was last readmitted on 10/13/2022 with diagnoses that included type 2 diabetes mellitus (high blood sugar), long-term use of insulin, difficulty in walking, hemiplegia (loss of ability to move on one side of the body) and hemiparesis (weakness on one side of the body) affecting the left non-dominant side, chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing problems), hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure resulting in the heart not pumping blood as well as it should), and pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid).   During a review of Resident 1's History and Physical (H&P), dated 10/15/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 10/27/2022, the MDS indicated Resident 1 required extensive assistance with bed mobility, transfers between surfaces including to and from bed, chair, wheelchair and standing position, dressing, toilet use, personal hygiene, and was completely dependent for bathing assistance. During a record review of Resident 1's social services progress notes, dated 3/18/2022 through 10/27/2022, the notes indicated the social services designee (SSD) contacted FM 1 one time, on 9/7/2022, regarding Resident 1's request to the discharged to FM 1's home. During a review of Resident 1's "Social Service Review," dated 10/7/2022, the record indicated Resident 1's discharge plan was to transfer to a lower level of care and the resident's discharge needs indicated a wheelchair was needed. The record indicated Resident 1 had no active discharge planning to return to the community at that time. During a review of Resident 1's "Multidisciplinary Care Conference," dated 10/7/2022, the record indicated Resident 1 was admitted to the facility for long-term care. The record indicated Resident 1 was to continue to gain strength with physical therapy services and had no active discharge planning to return to the community at that time. During a review of Resident 1's medical records, there were no care plans addressing Resident 1’s discharge planning. During a review of Resident 1's physician telephone order, dated 10/27/2022, the telephone order indicated to discharge Resident 1 to UTLF 1 with home health for medication management and safety. During a concurrent interview and record review with the SSD on 11/10/2022, at 5:16 p.m., Resident 1's physician order, dated 10/27/2022, was reviewed, the SSD confirmed the physician ordered home health for medication management and safety. The SSD stated she did not carry out the order for the home health referral because she thought the marketer who assisted her with the placement of Resident 1 had done it. The SSD stated she did not follow up to ensure the referral was made for home health because she assumed it was done. The SSD stated it was important to ensure the referral for home health was done because Resident 1 was discharged without the services he needed and that may lead to health problems for the resident and may result in hospitalization. During an interview on 11/7/2022, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he did not complete the discharge medication reconciliation for Resident 1 because he was very busy passing the afternoon medications and Resident 1 was leaving the facility in an hour. LVN 1 stated he was responsible for completing the medication reconciliation but gave the medications to the SSD and she completed the medication reconciliation form. LVN 1 stated he did not review the medications with Resident 1, he did not teach him how to check his blood sugar and did not teach him how to self-administer insulin because he did not have time to do it. LVN 1 stated it was important to reconcile the medications to ensure all the medications were accounted for and it was important to teach Resident 1 how to check his blood sugar so he could administer the correct insulin dose. LVN 1 stated it was important to teach the resident about his medications to ensure the resident took his medications correctly because it could lead to Resident 1 under or overmedicating himself, which may lead to complications such as high or low blood sugar and may lead to hospitalization. During an interview on 11/7/2022, at 3 p.m., with the SSD, the SSD stated she did not have any recent documentation indicating a discharge plan was discussed with Resident 1. The SSD stated Resident 1 informed her that family member (FM) 1 offered the resident to move in with him. The SSD stated she reached out to FM 1, but he “never” returned her telephone call, and she did not follow up on Resident 1's request to be discharged home with FM 1. The SSD stated it was important to follow-up with FM 1 to honor the request and preference of the resident to be discharged to FM 1’s home. The SSD stated Resident 1 was discharged to UTLF 1 because UTLF 1 approved his admission. The SSD stated she assumed UTLF 1 could provide the care Resident 1 required. The SSD stated Resident 1 was not given any details about UTLF 1 except for the address. The SSD stated she should have researched UTLF 1, and she should have known the services offered because Resident 1 was discharged to a facility that could not meet his needs. The SSD stated it was unsafe to send Resident 1 to UTLF 1 because it led to the resident not receiving the proper care and assistance which may have led to hospitalization and Resident 1 not feeling safe which may have affected his psychosocial well-being. During an interview on 11/10/2022, at 5:16 p.m., with the SSD, the SSD stated Resident 1 did not have an Interdisciplinary Team meeting (IDT, professional medical team plan, coordinate and deliver personalized health care) to address the resident’s discharge plan. The SSD stated it was important to have an IDT meeting for discharge planning so the resident and the IDT could be on the same page and ensure the resident’s discharge was safe. During a telephone interview on 11/15/2022, at 12:40 p.m., with Resident 1, Resident 1 stated when he left the facility (on 10/27/2022), he was taken to UTLF 1, and he was there for less than 20 minutes and was taken to UTLF 2 where there was "a bunch of crazy people." Resident 1 stated he was taken to the hospital after a day and a half because he complained of having chest pain. Resident 1 stated when he left UTLF 2, he was told he could not return to UTLF 2 because the facility staff could not give him the help he required. Resident 1 stated he required a lot of assistance to change his brief. Resident 1 stated the left side of his body was weak, so it was very hard to transfer himself in and out of the bed, that made him feel frustrated and was scared he might fall and hurt himself, but he had no other choice. Resident 1 stated he did not get the help he needed at UTLF 2, and it was hard and frustrating. Resident 1 stated he was not ready to leave the facility and felt he was discharged so fast because the facility needed his bed for someone else. Resident 1 stated he did not let the facility know he did not want to leave because he felt rushed out of the facility. Resident 1 stated he felt he was not given a choice whether he wanted to leave the facility because he was just told he was being transferred. Resident 1 stated it made him feel sad and felt he was not treated right by the facility. Resident 1 stated his discharge from the facility had been very hard for him because it affected his depression. Resident 1 stated he would like to return to the facility if he could. Resident 1 stated the facility did not teach him about his medications, how to check his blood sugar and self-administer insulin prior to being discharged to UTLF 1. Resident 1 stated his blood sugar was not checked and he did