Health inspection·November 27, 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. § 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 10/10/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was transferred from the facility to a General Acute Care Hospital (GACH 2) on 9/18/2024. GACH 2 tried to have Resident 1 readmitted to the facility on 10/1/2024, but the facility refused to readmit the resident because there were no beds available. On 10/11/2024, the CDPH conducted an unannounced visit to the facility to investigate the compliant allegation. Upon investigation, CPDH determined that Resident 1 was transferred to GACH 1 on 9/5/2024 for evaluation and treatment related to abnormal laboratory (labs) test results and was transferred from GACH 1 to GACH 2 on 9/18/2024. On 10/1/2024 the facility refused Resident 1 readmission to the facility after Resident 1 was treated and stabilized at GACH 2 on 10/1/2024 and was ready for discharge back to the facility because the facility had no isolation beds. The facility failed to: 1. Ensure Resident 1, who was transferred to GACH 1 on 9/5/2024 for evaluation and treatment related to abnormal lab results, was readmitted to the facility after Resident 1 was treated and stabilized at GACH 2 on 10/1/2024. 2. Follow their Policy and Procedure (P/P), titled, "Bed Hold Notice Upon Transfer," that indicated a resident whose hospitalization or therapeutic leave exceeds the bed hold period under the State plan will be readmitted to the facility immediately upon the first availability of a bed. 3. Follow an All Facility's Letter 24-15 (AFL 24-15), dated 6/13/2024, that indicated as of 3/20/2024, all Skilled Nursing Facilities (SNFs) in compliance with the Centers for Medicare & Medicaid Services ([CMS] an agency that provides health coverage to more than 160 million recipients) Enhanced Barrier Precautions ([EBP] an infection control strategy that uses personal protective equipment ([PPE] clothing and gear that medical professional wear to protect themselves from infection and injury to reduce the spread of Multidrug-resistant Organisms ([MDROs] bacteria that have become resistant to certain antibiotics in nursing homes) requirement, were able to admit and provide care for residents with MDROs. These deficient practices resulted in Resident 1 remaining at GACH 2 for 11 days after Resident 1 was deemed appropriate for transfer back to the facility but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility (10/11/2024), placing the resident at risk for confusion, disorientation related to displacement from a place that was considered Resident 1's home. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 68 year-old male, was admitted to the facility on 2/29/2024 with diagnoses including bipolar disorder (mania and depression combination), and extrapyramidal movement disorder (involuntary muscular movement caused by side effects of antipsychotic medications). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/5/2024, indicated Resident 1 had the ability to understand others, make himself understood and required maximal assistance (helper does more than half the effort) with 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) form dated 9/5/2024, indicated Resident 1's lab result (hemoglobin - an iron rich protein in red blood cells that carries oxygen from the lungs to the body's tissue and organs) were abnormal. A review of Resident 1's Physician's Order dated 9/5/2024 and timed at 5 p.m., indicated to transfer Resident 1 to the GACH (GACH 1). A review of Resident 1's Nurses Progress Notes dated 9/5/2024 and timed at 4:51 p.m., indicated Resident 1 was transferred to GACH 1 for further evaluation. During a review of the facility's Daily Census, the following was indicated: 1. From 10/1/2024 through 10/7/2024 - there was one male bed available 2. From 10/8/2024 through 10/9/2024 - there were three male beds available 3. From 10/10/2024 through 10/11/2024 - there were four male beds available A review of GACH 1's Admission Records (Face Sheet), indicated Resident 1 was transferred to GACH 1 on 9/5/2024 and discharged to GACH 2 on 9/18/2024. A review of GACH 2's Admission Record indicated Resident 1 was admitted to GACH 2 on 9/18/2024 and discharged to skilled nursing facility (SNF 2) on 10/11/2024. A review of GACH 2's Case Management/Social Services Assessment dated 10/11/2024, indicated the facility reported they had no available beds since 10/1/2024. During an interview on 10/11/2024 at 11:15 a.m., the Director of Nurses (DON) stated Resident 1 contracted Candida auris ([C. auris] a yeast that can cause life-threatening infections and is highly contagious in healthcare settings) at GACH 2 and she could not readmit Resident 1 to the facility because they had no available isolation beds. During an interview on 10/17/2024 at 2:30 p.m., Registered Nurse 1 (RN 1) stated, she spoke to someone at GACH 2, who reported Resident 1 had C. auris. RN 1 stated they did not refuse to readmit Resident 1 to the facility, but they did not have any isolation beds available. During an interview on 10/17/2024 at 2:40 p.m., the Administrator (ADM) stated they could not readmit Resident 1 because there were no available beds. During a telephone interview on 10/17/2024 at 4:30 p.m., the Social Worker (SW) from GACH 2 stated, she called the facility about Resident 1's discharge on 10/1/2024 and was told by RN 1 there were no available beds. A review of AFL 24-15, dated 6/13/2024, indicated as of 3/20/2024, all SNFs in compliance with CMS Enhanced Barrier Precautions requirement, were able to admit and provide care for residents with MDROs. Thus, there was no basis for the facility to refuse admission of a Resident based on the resident's need for EBP or MDRO status. Residents on EBP do not require placement in a single person room, even when known to be infected or colonized with an MDRO. A review of the facility's undated P/P titled "Bed Hold Notice Upon Transfer," indicated a resident whose hospitalization or therapeutic leave exceeds the bed hold period under the State plan will be readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility and is eligible for Medicaid nursing facility services. The facility failed to: 1. Ensure Resident 1, who was transferred to GACH 1 on 9/5/2024 for evaluation and treatment related to abnormal lab results, was readmitted to the facility after Resident 1 was treated and stabilized at GACH 2 on 10/1/2024. 2. Follow their P/P, titled, "Bed Hold Notice Upon Transfer," that indicated a resident whose hospitalization or therapeutic leave exceeds the bed hold period under the State plan will be readmitted to the facility immediately upon the first availability of a bed. 3. Follow an AFL 24-15, dated 6/13/2024, that indicated as of 3/20/2024, all SNFs in compliance with CMS EBP PPE requirement, were able to admit and provide care for residents with MDROs. These deficient practices resulted in Resident 1 remaining at GACH 2 for 11 days after Resident 1 was deemed appropriate for transfer back to the facility but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility (10/11/2024), placing the resident at risk for confusion, disorientation related to displacement from a place that was considered Resident 1's home. These violations jointly, separately, or in any combination, had a direct relationship to the health, safety, or security of Resident 1.