Health inspection·December 6, 2024

F710 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.30 Physician Services A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. 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. On 10/17/2024, the California Department of Public Health (CDPH), received a complaint related to concerns regarding quality of care and treatment. On 10/23/2024, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. While investigating the initial complaint allegation, an unrelated issue was brought to the surveyor's attention regarding a resident (Resident 1), who was signed out from the facility against medical advice ([AMA] a patient who leaves a medical facility before the physician recommends discharge) on 10/11/2024, by his Responsible Party (RP) who was also his conservator (a person appointed by the court to make decisions about a patient's personal matters such as medical care, food, clothing, and where the patient will live). Resident 1 returned to the facility on 10/14/2024, accompanied by his RP to have his gastrostomy tube ([GT] a surgical opening fitted with a device to allow nutrition and medication to be administered directly to the stomach common for people with swallowing problems) removed. The facility failed to: 1. Ensure Resident 1, who was discharged from the facility AMA on 10/11/2024, and who was no longer under the care of a physician at the facility, did not have a procedure performed on 10/14/2024 to remove his GT in the Director of Nurses (DON) office. 2. Follow the facility's policy and procedure (P/P), titled, "Admission and Orientation of Residents" indicating the facility will only admit residents in need of skilled nursing and/or long-care placement upon the order of an attending physician. This deficient practice resulted in Resident 1 undergoing a procedure at the facility where he no longer resided and where he had no assigned physician and/or orders/instruction for care. This deficient practice had the potential for Resident 1 to experience side effects related to the procedure including pain, bleeding, and infection. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 31-year-old male, was admitted to the facility on 8/14/2024 with the diagnoses including bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and dysphagia (difficulty swallowing), with a GT in place. A review of Resident 1's History & Physical (H&P) dated 8/15/2024 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/8/2024 indicated Resident 1's cognition was intact, and he required partial/moderate assistance (helper does less than half the effort) to complete his activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's Change of Condition (COC) note dated 10/10/2024 and timed at 7 p.m., indicated Resident 1 was last seen by Certified Nursing Assistant 1 (CNA 1) at 6:54 p.m., and she notified Licensed Vocational Nurse 1 (LVN 1) at 8 p.m., that she could not find Resident 1. The COC note indicated staff searched for Resident 1 inside and outside the facility, but he was not found. A review of Resident 1's Nurses Notes, dated 10/14/2024 indicated on 10/11/2024 at 9 a.m., Resident 1's RP came to the facility to pick up Resident 1's personal items and reported that Resident 1 was found in Westminster, CA. (16 miles away from the facility), and she would be signing him out from the facility AMA. The Nurses Notes indicated on 10/14/2024 (time unknown) the RP returned to the facility with Resident 1 to have his GT removed because he (Resident 1) felt safer coming to the facility and he did not want to go to a General Acute Care Hospital (GACH) to have the procedure performed. The Nurses Notes indicated Resident 1's GT was removed by Resident 1's physician's Physician Assistant ([PA] a health care professional who works under the supervision of a physician to provide medical treatment) in the DON's office. During an interview on 10/24/2024 at 5 p.m., the DON stated Resident 1's RP was concerned about Resident 1 having his GT in place while out on the street. The DON stated she wanted to ensure Resident 1 was safe and thought it was the best option for Resident 1 to have his GT removed at the facility. A review of the facility's P/P, titled "Admission and Orientation of Residents" dated 1/2024, indicated the facility will only admit residents in need of skilled nursing and/or long-term care placement upon the order of an attending physician. The resident must have been an inpatient of a hospital for a medically qualifying stay unless a waiver applies. The resident requires skilled services that are ordered by a physician and the services are rendered for a condition for which the resident received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he/she received inpatient hospital services The facility failed to: 1. Ensure Resident 1, who was discharged from the facility AMA on 10/11/2024, and who was no longer under the care of a physician at the facility, did not have a procedure performed on 10/14/2024 to remove his GT in the DON's office. 2. Follow the facility's P/P, titled, "Admission and Orientation of Residents" indicating the facility will only admit residents in need of skilled nursing and/or long-care placement upon the order of an attending physician. This deficient practice resulted in Resident 1 undergoing a procedure at the facility where he no longer resided and where he had no assigned physician and/or orders/instruction for care. This deficient practice had the potential for Resident 1 to experience side effects related to the procedure including pain, bleeding, and infection. These violations had a direct relationship to the health, safety, or security of Resident 1.