Health inspection·December 6, 2024

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) 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. (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. CCR 72523 (a) 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. On 10/23/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), who was transferred to a General Acute Care Hospital (GACH), was refused readmission to the Skilled Nursing Facility (SNF), where the resident was transferred from. On 10/24/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. During the investigation CDPH determined on 10/1/2024, Resident 1 was transferred to a GACH for evaluation of a possible small bowel obstruction ([SBO]-a blockage in the small intestine that prevents food, liquids, gas, and stool from passing through normally) and the GACH cleared Resident 1 to return to the facility on 10/11/2024, but the facility refused to readmit Resident 1. The facility failed to: 1. Re-admit Resident 1 to the facility on 10/11/2024 after the resident was evaluated, treated, and cleared by the GACH to return to the facility. 2. Ensure the facility followed its policy and procedure (P/P), titled "Bed Holds and Return" that indicated when a resident's hospital or therapeutic leave exceeds the bed-hold period, the facility will readmit the resident requiring SNF services to their previous room if available, or immediately upon the first availability of a bed in a semi-private room. This deficient practice resulted in Resident 1 being unable to return to the facility that had been considered her home, for about 12 months, once deemed appropriate for transfer back to the facility. Resident 1 had an unnecessarily prolonged stay of 14 days at the GACH placing Resident 1 at risk for unmet care needs, disorientation, confusion, psychosocial harm from being displaced and risk of acquiring nosocomial (acquired in a healthcare facility) infections. A review of Resident 1 a 64-year-old female's Admission Record dated 10/25/2024 indicated Resident 1 was admitted to the facility on 10/14/2023 with diagnoses including respiratory failure (a condition that makes it difficult to breath on one's own) requiring a tracheostomy (a surgical procedure that creates an opening in the neck to provide an alternative airway for breathing) and ventilator (a machine that helps patients breathe) dependence and a gastrostomy (a surgical opening fitted with a device to allow feedings, and medications to be administered directly to the stomach) present. A review of Resident 1's History and Physical (H&P) dated 9/26/2024, indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated the resident had a designated responsible party (RP) to make decisions. A review of Resident 1's Change of Condition (COC) form dated 9/30/2024 and timed at 7:30 a.m., indicated Resident 1 vomited once and had abdominal distention (swollen beyond normal size). The COC indicated the doctor ordered an x-ray (a type of imaging that shows different tissues in the body) of the kidney (an organ that filters out waste from the body and produces urine), ureter (tube in the body that carries urine from the kidney to the bladder [an organ that stores urine from the kidney], and bladder ([KUB] - diagnostic test used to assess the abdominal area). A review of Resident 1's COC form dated 10/1/2024 and timed at 6:30 p.m., indicated the facility informed the doctor of abnormal KUB results. The COC indicated a physician's order dated 10/1/2024 for Resident 1 to transfer to a GACH for further evaluation of the abnormal KUB results. A review of Resident 1's Nursing Progress Notes dated 10/1/2024 at 7:51 p.m. indicated Resident 1 was transferred to a GACH via ambulance (medical transport). A review of Resident 1's Notification of a 7-day Bed-Hold (facility reserves a bed for a resident that was transferred out emergently or pre-planned) form dated 9/26/2024 indicated the Bed-Hold Start date was 10/1/2024 and the Bed Hold Stop Date was 10/7/2024. A review of Resident 1's GACH Infection Status documentation dated 10/8/2024 indicated Resident 1's urine, collected on 10/2/2024, and resulted on 10/7/2024, indicated Resident 1's urine was positive for Klebsiella Pneumoniae (an infection caused by an organism that can lead to further infections) multi-drug resistant, and Pseudomonas Aeruginosa (bacteria found in the environment that can cause infections in blood, lungs, other parts of the body), and Carbapenem-resistant ([CRPA]-a type of bacteria that can cause serious infections and is highly resistant to antibiotics [medications used to treat infections]). A review of Resident 1's GACH Case Management (CM) notes dated 10/9/2024 at 12:34 p.m., indicated that on 10/9/2024 at 1:20 p.m., the facility stated they did not have any available beds in the sub-acute (a unit that provides a higher level of care than a skilled nursing unit) at this time. The CM notes indicated the facility stated they would accept Resident 1 back as soon as they had an isolation (precautions implemented to prevent the spread of infections from an infected person), bed available. A review of Resident 1's GACH Orders indicated a physician's order that was active from 10/11/2024 until 10/24/2024 to discharge Resident 1 from the GACH and to transfer to SNF once bed is available. A review of Resident 1's GACH CM notes dated 10/11/2024 at 2:11 p.m., indicated Resident 1 was stable for discharge, and the facility stated they did not have an isolation bed available. A review of Resident 1's GACH CM notes dated 10/15/2024 at 2:01 p.m. indicated Resident 1 was stable for discharge pending sub-acute placement, and the facility stated there were no isolation beds, and no other resident to cohort (to place two or more residents in one room) the resident. The GACH CM notes indicated the facility stated they were willing to accept Resident 1 back when an isolation bed became available. A review of Resident 1's GACH CM notes dated 10/18/2024 at 12:54 p.m., indicated Resident 1 was stable for discharge pending sub-acute placement, and the facility stated there were no isolation beds available that day and that the facility was still unable to accept Resident 1. During an interview with Resident 1's Responsible Party (RP) on 10/23/2024 at 4:13 p.m., Resident 1's RP stated that the facility was Resident 1's home, and Resident 1 was well-established at the facility. A review of the facility's Daily Census (number of residents in the facility on a given day) dated 10/7/2024 through 10/24/2024 indicated that there was one available bed in a shared female room each day. During an interview with the Director of Nursing (DON) on 10/25/2024 at 4:24 p.m., the DON stated that the other resident in the room with the unoccupied bed has a different MDRO, Carbapenem resistant Acinetobacter baumannii ([CRAB] - another type of bacteria that can cause serious infections and is highly resistant to antibiotics). The DON stated Resident 1 could not be placed in the same room with a resident that had a different type of infection. The DON stated the facility did not have single sub-acute rooms, only 2-bed and 3-bed rooms. The DON stated the facility did not have the beds to move residents around to give Resident 1 an entire room. A review of the California[AG1][IF2] Department of Public Health's (CDPH) All Facilities Letter ([AFL] - directions issued by CDPH to all facilities) 24-15 dated 6/13/2024 indicated a Carbapenem-Resistant Organisms (Pseudomonas, Acinetobacter species) indicated in a multi-bed rooms, healthcare provider (HCP) must treat each bed space as a separate room, which includes removing personal protective equipment ([PPE]- gowns and gloves used to decrease the spread of infection), and performing hand hygiene before putting on a new set of PPE prior to providing care between two residents in the same room. A review of the CDPH's website indicated Cohorting (placing resident's with similar risks of infection in the same room) Guidance for Residents Infected or Colonized with Multidrug-resistant Organisms for Skilled Nursing Facilities (SNF) document dated March 2023, indicated that "Facilities may not refuse to provide care for residents who are known to be infected or colonized with an MDRO per All Facilities Letter 22-21 (AFL - guidance from the Center for Health Care Quality (CHCQ) Licensing and Certification (L&C) Program to health facilities that may include changes in healthcare, enforcement, scope of practice, or general information that affects the health facility), inability to implement comprehensive cohorting guidance is not a basis for refusing admission of residents with an MDRO." (https://www.cdph.ca.gov/) A review of the facility's policy and procedure (P/P) titled, "Bed Holds and Returns," revised March 2022, indicated if a resident exceeds the stated 7 day bed-hold period, he or she will be permitted to return to the facility, to his or her previous room (if available) or immediately upon the first availability of a bed in a semi-private room provided the resident requires the services of the facility. The facility failed to: 1. Re-admit Resident 1 to the facility on 10/11/2024 after the resident was evaluated, treated, and cleared by the GACH to return to the facility. 2. Ensure the facility followed its P/P, titled "Bed Holds and Return" that indicated when a resident's hospital or therapeutic leave exceeds the bed-hold period, the facility will readmit the resident requiring SNF services to their previous room if available, or immediately upon the first availability of a bed in a semi-private room. This deficient practice resulted in Resident 1 being unable to return to the facility that had been considered her home, for about 12 months, once deemed appropriate for transfer back to the facility. Resident 1 had an unnecessarily prolonged stay of 14 days at the GACH placing Resident 1 at risk for unmet care needs, disorientation, confusion, psychosocial harm from being displaced and risk of acquiring nosocomial infections. This violation had a direct relationship to the health, safety, or security of the resident. [AG1]Please indicated a specific document i.e AFL [IF2R1]Done.