Health inspection·December 31, 2024

§483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and- (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. § 72523(a) 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 12/2/2024 the California Department of Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (Resident 1), left the facility on 11/30/2024 at approximately 2:10 p.m., against medical advice ([AMA] when a patient chooses to leave a hospital before the doctor recommends discharge) assisted by his spouse (significant other). However the significant other did not sign the AMA form and Resident 1's whereabouts were unknown for two days. On 12/3/2024 the CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation, the CDPH determined Resident 1, who was assessed with cognitive (the mental process of thinking, learning, remembering, being aware of surroundings and using judgement) impairment and the inability to make medical decisions, was allowed to leave from the facility AMA and without proper discharge planning when the facility was made aware that Resident 1's significant other had intentions of taking Resident 1 from the facility AMA. Resident 1's whereabouts were unknown to the facility for two days and when Resident 1 was found there was no assessment conducted by the facility nor were emergency services called (911) to determine if Resident 1's medical condition required further interventions. The facility failed to: 1. Ensure a care plan for Resident 1's safe discharge was developed when the facility was made aware of Resident 1's significant other's desire to have the resident leave the facility AMA, five days before Resident 1's significant other took Resident 1 from the facility without the facility's knowledge or permission. 2. Ensure Resident 1 was not taken from the facility by an unauthorized person (significant other) without the facility's knowledge or permission, resulting in Resident 1's whereabouts being unknown for two days, and upon location of Resident 1 at a homeless encampment, Resident 1 and the significant other were asked to discharge from the facility by signing an AMA form. 3. Ensure Resident 1 was assessed by facility staff, documenting Resident 1's medical condition when he was located at a homeless encampment two days after being taken from the facility, then asked Resident 1 and the significant other to sign the facility's AMA form, without prior discharge planning to ensure Resident 1 was safe and care was provided. 4. Ensure emergency services assessed Resident 1's medical status to determine if Resident 1 required transport to a GACH for evaluation and treatment as needed, instead facility staff asked Resident 1 and the significant other to sign the facility's AMA form, discharging Resident 1 from the facility without prior discharge planning ensuring Resident 1 was safely discharged. 5. Ensure Resident 1 and/or the significant other, who took him from the facility without the facility's knowledge or permission, was able provide care for Resident 1 before they (Resident 1 and the significant other) were asked to sign AMA discharge documents. 6. Ensure Resident 1's physician was notified when Resident 1's significant other made the facility aware of her intentions to take Resident 1 from the facility AMA. As a result of these failures, Resident 1, who was incontinent (involuntary voiding of urine and stool), non-ambulatory (inability to walk) with medical conditions/diagnoses that required medication, and whose cognition was severely impaired, was removed from the facility by an unauthorized person without the facility's knowledge or approval. Resident 1's whereabouts were unknown to the facility for two days before he was found residing in a homeless encampment approximately two miles from the facility. Resident 1 was found lying on the floor in a dark tent on a thin mattress and was subjected to poor weather conditions, unsanitary environmental conditions, he was without medication, discharge instructions, caregiver training or provisions necessary to properly care for himself. Resident 1 was at risk for deterioration of his medical condition, and death. A review of Resident 1's Admission Record (Face sheet), indicated Resident 1, a 68 year old male, was admitted to the facility on 11/22/2024 with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition that causes confusion, memory loss and loss of consciousness), status post (after or following) a stroke with right side hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body), functional quadriplegia (the lack of ability to use one's limbs or to ambulate due to extreme debility or frailty caused by another medical condition without physical injury or damage to the spinal cord), hypertension ([HTN] high blood pressure [BP]), dysarthria (speech that is slurred slow and difficult to understand), benign prostatic hypertrophy ([BPH] a condition in which the prostate is enlarged causing slow urine flow or blockage of urine from the bladder), a urinary tract infection ([UTI] an infection that affects all or part of the urinary tract including the bladder and kidneys), hypothyroidism (a condition when there is not enough hormones in the body to control the body's use of energy), generalized weakness and a history of repeated falls. The Face Sheet indicated there was no responsible person listed only a contact person (the significant other). The contact person listed had no documented contact information, such as address or telephone number. A review of Resident 1's MDS, dated 11/25/2024, indicated Resident 1 was not able to make decisions for himself, was incontinent of bladder and bowel functions, was non ambulatory, and was totally dependent on two or more staff 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 H&P dated 11/23/2024, indicated Resident 1 was able to make his needs known but could not make medical decisions. A review of Resident 1's Physician's Order, dated 11/22/2024, indicated Resident 1 was incapable of giving informed consent (a process where a patient is given clear and comprehensive information about a particular action, procedure, or situation, to ensure they understand the risks, benefits, alternatives, and potential consequences of medical interventions) and he was unable to participate in his plan of care. A review of Resident 1's Physician's Order, dated 11/22/2024 indicated the following medications were prescribed to Resident 1: 1. Norvasc (a medication used to treat high blood pressure) 2.5 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) one tablet daily for HTN hold for systolic BP (the top number in a BP reading) of less than 100. 2. Doxazosin Mesylate (a medication used to treat urinary problems caused by an enlarged prostate, which includes difficulty urinating) 2.0 mg one tablet daily for BPH. 3. Lipitor (a medication that lowers cholesterol) 20 mg 1 tablet by mouth at bedtime for hyperlipidemia (abnormally elevated levels of any or all lipids [fats] in the blood). 4. Hydrocodone Acetaminophen (a pain medication) 5/325 mg one tablet every four hours as needed for moderate to severe pain 5. Levoxyl (a medication that contains and replaces a hormone) 50 micrograms ([mcg] a metric unit of measurement, used for medication dosage and/or amount) one tablet daily for hypothyroidism. 6. Protonix (a medication that treats gastroesophageal reflux ([GERD] a condition in which the stomach contents leak backwards from the stomach into the esophagus [the tube from the mouth to the stomach], and stomach ulcers) 40 mg one tablet daily for GERD. A review of Resident 1's Physician's Progress Notes dated 11/27/2024, indicated Resident 1 was admitted to the facility on 11/22/2024 with a chief compliant of weakness and an altered level of consciousness ([ALOC] a condition of not being alert, awake or able to understand) for skilled rehabilitation (care that can help a person get back, keep, or improve abilities needed for daily life) with a goal of retraining Resident 1 to improve his coordination/balance, self-care abilities, pain management, and to monitor his cognition to reduce the risk of falls and accidents. A review of Resident 1's untitled Care Plan, dated 11/25/2024, indicated Resident 1 needed retraining in skills to enable his return to community. The Care Plan's goal was for Resident 1 to be safely discharged to an appropriate level of care with interventions including collaboration with Resident 1, his RP and physician to ensure Resident 1's appropriate placement. The Care Plan indicated to follow up with home health services such as physical therapy ([PT] treatment that helps improve how the body performs physical movement), occupational therapy ([OT] treatment that focuses on helping individuals improve their ability to engage in meaningful ADLs) and nurse services, to provide education and training to Resident 1 and his RP as needed for safety, discharge instructions and a detailed summary of Resident 1's care upon discharge to assure his continuity of care. A review of Resident 1's Nurses Progress Notes dated 11/25/2024 and timed at 4:14 p.m., and 5:43 p.m., and a subsequent Nurses Progress Notes dated 11/27/2024 and timed at 3:15 p.m., indicated Resident 1's significant other (who was identified only as Resident 1's contact without any contact information provided) refused to sign Resident 1's admission documents, treatment plan and refused to provide her contact information. The Nurses Progress Notes indicated Resident 1's significant other wanted to take Resident 1 out of the facility. A review of Resident 1's Social Services Assessment dated 11/27/2024 and timed at 3:39 p.m., indicated Resident 1's significant other stated she would take Resident 1 out of the facility. A review of Resident 1's Skilled Charting dated 11/28/2024 and timed at 1:14 p.m., indicated Resident 1's significant other threatened to take Resident 1 out of the facility AMA because she felt Resident 1 was not making any progress. A review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 11/30/2024 and timed at 3:24 p.m., indicated at 2:30 p.m., on 11/30/2024, the facility did not find Resident 1 in his bed and Resident 1's roommate reported Resident 1's significant other took Resident 1 for a walk. A review of Resident 1's Social Service Note dated 12/2/2024 and timed at 5:48 p.m., indicated Resident 1 and the significant other was located at a homeless encampment, paramedics were called for a wellness check but only a police officer arrived. The Social Service Note indicated Resident 1's significant other stated to the police officer, in the presence of the SSD, that Resident 1 would be okay with her because she had a "hex" on Resident 1. The Social Service Note indicated Resident 1 was able to state his name and birthdate and that he wanted to stay with the significant other, they (Resident 1 and the significant other) signed the facility's AMA form. During an interview on 12/4/2024 at 11 a.m., Resident 2 stated he was Resident 1's roommate and Resident 1 was not able to express himself and would only mumble. Resident 2 stated Resident 1 had a female visitor, referring to the significant other, that would visit him every other day. Resident 2 stated, on a Saturday afternoon (11/30/2024) he overheard the female visitor telling Resident 1 they were going for a walk, and they left the room with the female visitor pushing Resident 1 in a wheelchair. During an interview on 12/4/2024 at 5:21 p.m., the SSD stated the DON and other licensed nurses were aware (11/25/2024) that Resident 1's significant other voiced her intention of taking Resident 1 out of the facility AMA. The SSD stated on 11/30/2024 the significant other took Resident 1 out of the facility without staff knowledge or permission. The SSD stated on 12/2/2024 (two days after Resident 1 was taken from the facility) after 3 p.m., Resident 1 was found in a homeless encampment with the significant other, two miles away from the facility, they were living in a dark tent, and Resident 1 was lying on a thin mattress on the ground. The SSD stated she called the paramedics, but a police officer showed up. The SSD stated the police officer spoke to Resident 1 and determined Resident 1 was in no distress because he (Resident 1) knew his name, his date of birth and voiced he (Resident 1) wanted to stay at the homeless encampment with the significant other. The SSD stated Resident 1's significant other when questioned, stated not to worry about Resident 1 because she had a "hex" on him, and he would be okay. The SSD stated the DON had Resident 1 and the significant other signed the facility's AMA form. The SSD stated Resident 1's discharge was unsafe, and it was not the discharge process that the facility encouraged. The SSD acknowledged that Resident 1's significant other took the risk and put Resident 1 in a d