Health inspection·January 10, 2025

Code of Federal Regulations, Title 42, §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. Code of Federal Regulations, Title 42, Section §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. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (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. (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. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (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. California Code of Regulations, Title 22, Section 72433. Social Work Service Unit - Services. (b) Social work services unit shall include but not be limited to the following: (5) Discharge planning for each patient and implementation of the plan. California Code of Regulations, Title 22, Section 72547. Content of Health Records. (a) A facility shall maintain for each patient a health record which shall include: (10) Discharge planning notes when applicable. (14) Condition and diagnoses of the patient at time of discharge or final disposition. California Code of Regulations, Title 22, Section 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. On 11/26/24, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding admission, transfer, and discharge, and quality of care. As a result of the investigation, the CDPH determined the facility failed to provide a safe discharge for Resident 1 and Resident 2 as indicated in the facility's policies and procedures (P&P) and failed to implement the discharge plan for Resident 1 and Resident 2 by failing to: 1. Ensure Resident 1 and Resident 2 were discharged to an appropriate facility that was able to provide the level of care Resident 1 and Resident 2 needed such as assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and medications, blood sugar checks, insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration, and wound care. Resident 1 and Resident 2 were discharged to an Independent Living Facility (ILF- housing arrangement which does not provide care, supervision, or assistance with daily activities). 2. Ensure Resident 1 was discharged to ILF 3 as indicated in the physician's order and "Notice of Transfer/Discharge." Resident 1 was discharged to ILF 1 instead of ILF 3. 3. Ensure Resident 1's physician's order for discharge indicated a referral for home health services. Resident 1 had a wound on the left lower leg which required daily wound treatment. 4. Ensure Licensed Vocational Nurse (LVN) 1 included a skin assessment on Resident 1's discharge note. 5. Ensure the Social Services Designee (SSD) documented Resident 1 verbalized to the SSD that Resident 1 wanted to leave the facility. These violations resulted in an unsafe discharge of Resident 1 and Resident 2 and had the potential to negatively impact Resident 1's and Resident 2's health, safety, and well-being. 1a. A review of Resident 1's Admission Record (AR) indicated Resident 1, a 76-year-old male, was readmitted to the facility on 8/21/24, with multiple diagnoses which included Alzheimer's Disease, diabetes mellitus, and schizophrenia. The AR indicated Resident 1 was self-responsible. A review of Resident 1's Minimum Data Set (MDS), dated 10/21/24, indicated Resident 1 had moderately impaired cognition. The MDS indicated Resident 1 required setup or clean-up assistance with eating, oral hygiene, toileting hygiene, and wheeling Resident 1's manual wheelchair. Resident 1 required supervision or touching assistance with rolling in bed, sitting to lying and lying to sitting in bed, standing from sitting in a chair, wheelchair, or on the side of the bed. Resident 1 required partial/moderate assistance with upper and lower body dressing, personal hygiene, putting on/taking off footwear, chair/bed to chair transfer, and tub/shower transfer. Resident 1 required substantial/maximal assistance with showering/bathing. A review of Resident 1's History and Physical, dated 11/6/24, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's "IDT (Interdisciplinary Team) Conference Record - Wound Management (IDT Record)" dated 11/15/24, timed at 12:47 pm, indicated Resident 1 had a new wound on the left lower leg. A review of Resident 1's physician's order (PO), dated 11/15/24, indicated to apply a calcium alginate dressing to Resident 1's left lower leg wound daily. A review of Resident 1's PO, dated 11/25/24, indicated Resident 1 may be discharged to ILF 3 at [address of ILF 3]. The PO did not indicate discontinuation of Resident 1's medications, insulin sliding scale, wound treatment and did not indicate a referral for home health services once Resident 1 moved to ILF 3. A review of Resident 1's "Notice of Transfer/Discharge," dated 11/25/24, indicated Resident 1 was discharged to ILF 3, but Resident 1 was discharged to ILF 1. A review of Resident 1's Discharge Summary Note, written by LVN 1, dated 11/25/24, timed at 2:30 pm, indicated the discharge notes did not include an assessment of Resident 1's skin and the condition of Resident 1's left lower leg wound upon discharge. A review of Resident 1's medical record indicated there was no documented evidence the facility assessed Resident 1's knowledge and educated Resident 1 on how to care for Resident 1's left lower leg wound, how to check Resident 1's blood sugar before meals, and how to self-administer insulin according to the insulin sliding scale. A review of Resident 1's medical record indicated there was no documented evidence Resident 1 verbalized to the SSD that Resident 1 wanted to leave the facility. 1b. A review of Resident 2's AR indicated Resident 2, a 69-year-old male, was originally admitted to the facility on 6/20/24, and readmitted to the facility on 11/22/24, with diagnoses which included seizures and schizoaffective disorder. A review of Resident 2's MDS, dated 11/11/24, indicated Resident 2 had modified independence with making decisions regarding tasks of daily life. The MDS indicated Resident 2 required setup or clean-up assistance with eating and required supervision or touching assistance with oral hygiene, toileting hygiene, upper body dressing, rolling in bed, sitting to lying in bed, and walking 10 feet. The MDS indicated Resident 2 required partial/moderate assistance with showering/bathing, lower body dressing, putting on/taking off footwear, personal hygiene, lying to sitting on side of bed, standing from sitting in a chair, wheelchair, or on the side of the bed, tub/shower transfer, and walking 50 feet with two turns. A review of Resident 2's H&P, dated 11/23/24, indicated Resident 2 could make needs known but could not make medical decisions due to psychiatric reasons. A review of Resident 2's PO, dated 11/25/24, indicated to discharge Resident 2 to ILF 2 and a referral for home health services once Resident 2 moved to ILF 2. The PO did not indicate discontinuation of Resident 2's medications upon discharge. A review of Resident 2's medical record indicated there was no documented evidence the facility assessed and educated Resident 2 on how to self-administer medications. During an interview on 11/26/24 at 12 pm with the SSD, the SSD stated Resident 2 was discharged to a locked residential care facility for the elderly (RCFE) which specialized in dealing with psychiatric individuals. The SSD stated Resident 2 was self-responsible and was discharged to ILF 2. The SSD stated Resident 1 was discharged to ILF 2 on 11/25/24 and the Contact Person for ILF 2 (CP 1) was made aware Resident 1 could only stand while holding on to a certified nursing assistant (CNA) and could transfer from chair/bed to chair with assistance. The SSD stated before the facility released a resident for discharge, the facility would explain to the individual receiving the resident what care requirements the resident needed. The SSD stated the SSD knew ILF 2 and ILF 3 were licensed and employed caregivers who can provide assistance because RCFEs provided to the facility through the assisted living waiver (ALW) program were already licensed. The SSD stated CP 1 showed SSD a copy of ILF 3's license. The SSD stated residents were discharged based on their cognition, their finances, what city the resident wanted to move to, and if the resident had any medical need or wounds. During a subsequent interview on 11/26/24 at 2:23 pm with the SSD, the SSD stated home health care nurse would do the wound care for Resident 1. The SSD reviewed Resident 1's medical record and was unable to find documented evidence that Resident 1 verbalized to the SSD Resident 1 wanted to leave the facility. The SSD stated the SSD should have documented that Resident 1 requested to move to a lower level of care. The SSD stated Resident 1 had no family or friends. The SSD stated the SSD did not know Resident 1 had Alzheimer's disease. During an interview on 11/26/24 at 3:35 pm with LVN 1, LVN 1 stated on 11/25/24, Resident 1's physician gave an order to discharge Resident 1 with home health services for wound care. LVN 1 reviewed Resident 1's physician's order, dated 11/25/24. LVN 1 stated LVN 1 should have included and documented home health services when LVN 1 wrote in Resident 1's physician's discharge order. During an interview on 11/26/24 at 3:45 pm with the Director of Nursing (DON), the DON stated the SSD must document everything that was related to the resident's care and stay in the resident's medical record and all physician's discharge orders must include home health services, therapy, treatment, and equipment as ordered. The DON stated residents must be discharged to the facility specified in the physician's orders and discharge assessment, including skin assessment, must be documented in the resident's medical record. During a subsequent interview on 11/26/24 at 4 pm with the DON and the SSD, the DON and the SSD reviewed ILF 3's license which CP 1 provided to the SSD. The license belonged to RCFE 4's and was not ILF 3's. The address on RCFE 4's license was different from ILF 3's address given to the SSD by CP 1 and where Resident 1 was discharged to. The SSD stated the SSD did not realize the license was RCFE 4's and was not ILF 3's. The DON stated it was important to verify the license of the RCFE receiving the resident prior to discharge and ensure the discharging facility was able to provide the level of care the resident needed to ensure a safe discharge. During a phone interview on 11/26/24 at 4:19 pm with CP 1, CP 1 stated CP 1 was the supervisor of ILF 1 which had a different address from ILF 3. CP 1 stated Resident 1 left the skilled nursing facility and came straight to ILF 1 and not to ILF 3. CP 1 stated Resident 1 was currently in ILF 1 along with two other residents. CP 1 stated ILF 1 was not licensed because it was an independent living facility and residents who lived in ILF 1 were on their own. When CP 1 was asked if Resident 1 needed supervision and/or assistance, CP 1 stated Resident 1 would not stay in ILF 1 because there were no caregivers in ILF 1. CP 1 stated, "We do not keep them (residents) here. They (residents) go to the licensed place (RCFE 4)." CP 1 stated, "They (residents) are moving to the legal board and care (RCFE 4) and not staying here." During a phone interview on 11/26/24 at 4:55 pm with Resident 1, Resident 1 stated Resident 1 had not heard anything regarding moving to another facility. After speaking with Resident 1, CP 1 took the phone from Resident 1 and stated CP 1 was just on the phone with the individual who would pick up Resident 1 to move Resident 1 to RCFE 4. During an interview on 11/26/24 at 5 pm with the SSD, the SSD stated the SSD thought it was safe to discharge residents to ILF 2 and ILF 3 because ILF 2 and ILF 3 were referred to the SSD by other RCFEs under the ALW program and able to provide the level of care Resident 1 and 2 needed. The SSD stated the SSD asked CP 2 over the phone if ILF 2 was licensed and CP 2 told the SSD CP 2 owned several RCFEs which were licensed and had caregivers available except for the independent living facilities. During a telephone interview on 11/26/24 at 5:05 pm with CP 2, CP 2 stated CP 2 owned ILF 2 which was an independent living facili