Health inspection·December 31, 2024

§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) as they apply to discharges. 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 12/11/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was placed on a 5150 hold (an involuntary 72-hour detainment of a person who experiences a mental health crisis and is evaluated to be a danger to others, to himself/herself, or is gravely disabled) and sent to a General Acute Care Hospital (GACH), when the resident was psychiatrically stable for discharge back to the facility, the facility refused to take Resident 1 back and had filled his bed space. The Complaint indicated Resident 1 had nowhere to go and expressed that he wanted to return to the facility. On 12/12/2024 the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. During the investigation CDPH determined on 12/9/2024 Resident 1 was placed on a 5150 hold and transferred to a GACH due to the resident's combative behavior after he was found with drug paraphernalia (any equipment that is used to produce, conceal, and consume illicit drugs). On 12/11/2024, the GACH cleared Resident 1 to return to the facility, but the facility refused to readmit Resident 1. The facility failed to: 1. Ensure Resident 1's bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) agreement dated 12/9/2024 was honored by readmitting Resident 1 to the facility once he was evaluated, treated, and cleared by the GACH to return to the facility on 12/11/2024. 2. Ensure the facility followed their policy and procedure (P/P), titled "Bed Hold" that indicated the facility will hold the resident's bed for up to seven (7) days if the resident was transferred to a GACH, as long as the resident or resident's representative notified the facility within 24 hours of the transfer that they wished to have the facility hold the resident's bed. As a result, Resident 1 was denied seven days bed hold, refused readmission back to the facility which lead to Resident 1 remaining at the GACH for two days after the GACH deemed Resident 1 able to return to the facility. These failures placed Resident 1 at risk for continued displacement from his residence. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 71-year-old male, was admitted to the facility on 10/15/2024 with a diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow, imprecise movements). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 10/22/2024 indicated Resident 1's cognition was intact and Resident 1 required supervision or touch assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to complete activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). A review of Resident 1's Nurses Notes dated 12/9/2024 indicated Resident 1 was sent to the GACH due to aggressive behavior and danger to self and others. The Nurses Notes indicated Resident 1 was combative and trying to strike the facility staff when drugs and drug paraphernalia were found in his possession and confiscated. A review of Resident 1's Bed Hold Notification form dated 12/9/2024 indicated Resident 1 desired a bed hold for a duration of seven days and was verbally notified of his bed hold agreement. A review of Resident 1's Notice of Transfer/Discharge note (a written or verbal notification that a resident or their representative intends to leave a skilled nursing facility [SNF] or the SNF initiates the transfer or discharge) dated 12/9/2024 indicated Resident 1 was transferred to a GACH for the resident's welfare and the resident's needs could not be met at the facility. The Notice of Transfer/Discharge was not signed by the resident. A review of the facility's Census (a form documenting the number of residents receiving care at a given time) dated 12/12/2024 indicated Resident 1's room was listed as "EMPTY," and there was no resident's name assigned to the room. A review of the GACH's Face Sheet indicated Resident 1 was admitted to the Emergency Department (ED) on 12/10/2024. A review of Resident 1's Psychiatry ED Progress Note, dated 12/11/2024, indicated Resident 1 was placed on a 5150-hold due to being hostile to staff in the facility, disoriented, and unable to care for himself. The Psychiatry ED Progress Note indicated Resident 1 had significantly improved compared to when he initially presented to the emergency room, and he expressed a desire to go back to the facility. The Psychiatry ED Progress Note indicated Resident 1 was calm and cooperative and seemed back to his baseline level. The Psychiatry ED Progress Note indicated the plan was to discontinue Resident 1's 5150 hold when Resident 1's discharge back to the facility was arranged. A review of Resident 1's Behavioral Health Social Work Progress Note dated 12/11/2024, indicated the facility refused to readmit Resident 1 to the facility because the facility had given Resident 1's bed away to another resident. The Behavioral Health Social Work Progress Note indicated Resident 1 was psychiatrically and medically stable for discharge back to the facility. During an interview on 12/12/2024 at 9:17 a.m., the GACH Social Worker (SW) stated the Medical Director (MD) of the ED spoke to one of the staff members (unidentified) at the facility and the facility was under the impression Resident 1 was being taken to jail and he no longer had a bed at the facility. The GACH SW stated the facility informed the MD that Resident 1 should be discharged to a residential substance abuse program (treatment for those suffering from addiction to drugs and/or alcohol) for rehabilitation. The GACH SW stated Resident 1 did not meet criteria for admission to the GACH. During an interview on 12/12/2024 at 12:49 p.m., the Director of Nursing (DON) stated she informed the MD at the GACH that Resident 1 required a substance abuse program, and she was not sure how the facility could help Resident 1 with his drug problems. The DON stated she did not tell the GACH the facility would not readmit Resident 1 but instead Resident 1 should be admitted to a different type of facility, one that could help him with substance abuse. A review of the facility's P/P titled "Bed Hold" dated 10/1/2023, indicated the facility will hold the resident's bed for up to seven (7) days if the resident was transferred to a GACH, as long as the resident or resident's representative notified the facility within 24 hours of the transfer that they wish to have the facility hold the resident's bed. The facility failed to: 1. Ensure Resident 1's bed hold agreement, dated 12/9/2024 was honored by readmitting Resident 1 to the facility once he was evaluated, treated, and cleared by the GACH to return to the facility on 12/11/2024. 2. Ensure the facility followed their P/P, titled "Bed Hold" that indicated the facility will hold the resident's bed for up to seven (7) days if the resident was transferred to a GACH, as long as the resident or resident's representative notified the facility within 24 hours of the transfer that they wished to have the facility hold the resident's bed. As a result, Resident 1 was denied a seven day bed hold, refused readmission back to the facility which lead to Resident 1 remaining at the GACH for two days after the GACH deemed Resident 1 able to return to the facility. These failures placed Resident 1 at risk for continued displacement from his residence. This violation had a direct relationship to the health, safety, or security of the patient.