Health inspection·April 15, 2025

Transfer and discharge 42 CFR § 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— (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 22 CFR § 72521. Administrative Policies and Procedures. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. 22 CFR § 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. On 3/10/2025, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to: 1. Ensure Resident 34 had a safe discharge by failing to follow Resident 34’s care and whereabouts after Resident 34 was transferred to the general acute care hospital (GACH) 1 after an unwitnessed fall. This resulted in the facility being misinformed of Resident 34’s whereabouts and had the potential to result in Resident 34’s discharge needs being unmet. Resident 34 was an 83-year-old male, admitted to the facility on 2/5/2025 with diagnoses that included nontraumatic subdural hemorrhage (a collection of blood that accumulates between the brain the inner lining of the skull without any prior head trauma), dementia (a progressive state of decline in mental abilities), and urinary tract infection ([UTI], an infection in the bladder/urinary tract). A review of Resident 34’s Minimum Data Set ([MDS], dated 2/12/2025, indicated Resident 34’s cognitive skills (process of thinking) for daily decision making was severely impaired. The MDS indicated Resident 34 was dependent on staff’s assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and moving from a sit to stand position. A review of Resident 34’s History and Physical Examination (H&P), dated 2/7/2025, indicated Resident 34 did not have the capacity to understand and make decisions. A review of Resident 34’s situation, background, assessment, recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) document, dated 2/22/2025, indicated on 2/22/2025 at 9:40 p.m., Resident 34 had an unwitnessed fall and was found sitting on the floor next to his bed. A review of Resident 34’s Nurse’s Notes, dated 2/23/2025 and timed at 10 a.m., indicated Family Member (FM) 1 was informed of Resident 34’s fall on 2/22/2025 and FM 1 requested for Resident 34 to be sent to GACH 1 for further evaluation. A review of Resident 34’s Nurse’s Notes, dated 2/23/2025 and timed at 10:30 a.m., indicated Physician 1 ordered to transfer Resident 34 to GACH 1 for further evaluation due to Resident 34 falling and Resident 34’s history of having a subdural hemorrhage (a collection of blood that accumulates between the brain the inner lining of the skull). A review of Resident 34’s Progress Notes, dated 2/23/2025 and timed at 1:20 p.m., indicated Resident 34 was transferred to GACH 1. During an interview on 3/13/2025 at 4:10 p.m., FM 2 stated on 2/23/2025, she and FM 1 went to the facility to take Resident 34 home because Resident 34 was discharged. FM 2 stated when they arrived at the facility, they were informed on 2/22/2025, Resident 34 fell. FM 2 stated the facility was unable to give them details of Resident 34’s fall, so they requested the facility to send Resident 34 to the GACH for further evaluation. FM 2 stated they did not sign the discharge paperwork because Resident 34 was transferred to GACH 1 in the afternoon on 2/23/2025 where GACH 1’s physician recommended Resident 34 to be transferred to GACH 2 for a neurosurgery (surgical specialty that focuses on the diagnosis and treatment of disorders and injuries affecting the brain, spinal cord, and nerves) consult due to subdural hemorrhage. FM 2 stated on the evening of 2/23/2025, Resident 34 was transferred from GACH 1 to GACH 2. FM 2 stated when Resident 34 was evaluated at GACH 2, the neurosurgeon informed FM 2 that surgery was not recommended to treat Resident 34’s subdural hemorrhage to maintain the resident’s quality of life. FM 2 stated on the evening of 2/25/2025, Resident 34 was discharged from GACH 2 to home. During an interview on 3/13/2025 at 4:54 p.m., the facility’s Admission Coordinator (AC) stated when a resident was transferred to the GACH, she was responsible for calling the GACH the following day to gather information on the resident’s status, whether the resident was admitted to the GACH, and the expected discharge date. The AC stated gathering this information was essential to know of the resident’s well-being and safety. The AC stated after Resident 34 transferred to GACH 1 on 2/23/2025, she called GACH 1 on 2/25/2025 to inquire on Resident 34’s status. The AC stated the Case Manager at GACH 1 informed her that Resident 34 was discharged home. The AC stated after she was informed of Resident 34’s discharge, she informed the Director of Nursing (DON), but did not call Resident 34’s family to follow up on Resident 34’s well-being. The AC stated she should have called Resident 34’s family to ensure Resident 34 was well and to provide any assistance the resident may need after Resident 34’s stay at GACH 1. The AC stated Resident 34 was not officially discharged from the facility and the facility was responsible for ensuring Resident 34 was safe. The AC stated because she did not conduct a follow-up call to Resident 34’s family she was unaware that Resident 34 was transferred to GACH 2. The AC stated on 2/26/2025, GACH 2 called the facility, to inquire if Resident 34 previously resided in the facility. The AC stated she did not find out why GACH 2 inquired about Resident 34’s previous residency. The AC stated due to Resident 34’s transfer to GACH 2, the facility was responsible for calling GACH 2 for Resident 34’s status and to assist with Resident 34’s discharge needs. The AC stated she did not conduct a follow-up with Resident 34’s family when she was misinformed of Resident 34’s discharge to home because Resident 34 was initially due to discharge home, from the facility on 2/23/2025 and all medical devices and appointments were confirmed. The AC stated because the facility did not conduct the necessary follow-ups with Resident 34’s family, the facility was unaware of Resident 34’s transfer to GACH 2 and of any additional needs and assistance Resident 34 may have needed on his discharge home on 2/25/2025. The AC stated conducting necessary follow-ups and following Resident 34’s transfer from GACH 1, to GACH 2, then to his home, would ensure Resident 34 had a safe discharge. The AC stated due to the lack of follow-ups and inappropriate discharge, Resident 34 was at risk of not receiving assistance and post-discharge care. During an interview on 3/13/2025 at 5:08 p.m., the DON stated Resident 34 was scheduled for discharge from the facility on 2/23/2025, however, was transferred to GACH 1 per FM 1 and FM 2’s request. The DON stated at the time, she did not feel a follow-up call to Resident 34’s home was necessary due to Resident 34’s prior discharge plan. The DON stated because Resident 34 was discharged from GACH 1, any additional discharge needs would be fulfilled by GACH 1. The DON stated the facility was responsible for Resident 34’s well-being because Resident 34 was not officially discharged from the facility on 2/23/2025. The DON stated the facility should have called Resident 34’s family to ensure Resident 34 was safe and did not require any additional assistance. The DON stated when the AC received a call from GACH 2, the AC should have inquired further about Resident 34’s status. The DON stated this was a missed opportunity to gain knowledge of Resident 34’s transfer from GACH 1 to GACH 2. The DON stated because there was no follow-up on Resident 34’s status, the facility was unaware of Resident 34’s transfer to GACH 2. The DON stated the facility was responsible for ensuring it was appropriate and safe for Resident 34 to be discharged home. The DON stated the sole purpose of following Resident 34’s whereabouts was to ensure Resident 34 was safe. The DON stated because the facility did not follow-up on Resident 34’s whereabouts, Resident 34 was at risk of being discharged inappropriately and unsafely. During an interview on 3/13/2025 at 5:41 a.m., with the Administrator (ADM), the ADM stated the facility did not have a policy that indicated how to follow-up with a resident’s transfer from the facility to the GACH and to home. The ADM stated it was the standard of practice to follow up with the resident throughout all aspects of care after transfer and discharge. A review of the facility’s policy and procedure (P&P) titled, “Notice of Transfer/Discharge”, revised 10/2017, indicated the facility may not transfer or discharge the resident unless “the transfer or discharge is appropriate because the resident’s health as improved sufficiently so the resident no longer needs the services provided by the facility.” The facility failed to: 1. Ensure Resident 34 had a safe discharge by failing to follow Resident 34’s care and whereabouts after Resident 34 was transferred to GACH 1 after an unwitnessed fall. This resulted in the facility being misinformed of Resident 34’s whereabouts and had the potential to result in Resident 34’s discharge needs being unmet. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.