Health inspection·May 29, 2024

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. 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 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 4/16/2024, 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. This violation resulted in Resident 1 being unsafely discharged with nowhere to stay, after being discharged 497 miles away from the facility. A review of Resident 1's Face Sheet (FS) indicated the facility readmitted Resident 1, a 66-year-old female, on 7/15/23, with diagnoses that included other abnormalities of gait and mobility, unspecified psychosis (a mental disorder characterized by a disconnection from reality), and Type 2 diabetes mellitus. The FS indicated Resident 1 was self-responsible, and the facility listed Family Member (FM) 1 as Resident 1’s emergency contact. A review of Resident 1's Quarterly Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/17/24, indicated Resident 1 had intact cognition. A review of Resident 1's Discharge Care Plan (CP) dated 2/20/24, indicated Resident 1 had a potential for discharge to home with assistance. The CP indicated Resident 1's goal was to move with FM 1 at FM 1’s address. The CP interventions included for Social Services Director (SSD) to schedule and communicate with Resident 1 and/or Resident 1’s responsible party regarding any needs and/or follow up appointment and identify any discharge barriers and assist in a safe discharge for Resident 1. A review of Resident 1's Interdisciplinary Team (IDT, providers from various specialties with diverse knowledge to help patients receive the care they need) Care Plan Conference Summary (IDT notes) dated 4/3/24, indicated the facility staff (unidentified) spoke to FM 1. The IDT notes indicated when FM 1 was asked if Resident 1 was coming home to FM 1’s address, FM 1 stated, "She's (Resident 1) not coming to the house, that's a stupid question, take her (Resident 1) wherever she (Resident 1) wants to go." The IDT notes indicated Resident 1 was self-responsible, and Resident 1 stated she (Resident 1) was going to be discharged to her (Resident 1's) home (FM 1’s address). A review of Resident 1's Notice of Transfer/Discharge dated 4/15/24, indicated Resident 1 would be transferred/discharged to FM 1's address. A review of Resident 1's Discharge Summary/Comprehensive Assessment dated 4/15/24, indicated Resident 1 required assistance for bathing, dressing, eating, personal hygiene, transferring, bed mobility, toilet use, and ambulation. During a telephone interview on 4/16/24 at 2:32 pm, FM 1 stated Resident 1 was currently at the Social Services Department. FM 1 stated FM 1 informed the facility’s Social Worker that FM 1 had no means to take care of Resident 1. FM 1 stated Resident 1 could not come to FM 1's home address. FM 1 stated the facility's staff dropped off Resident 1 and Resident 1's belongings which included four “gigantic” duffel bags and boxes. FM 1 stated Resident 1 required a lot of assistance. FM 1 stated FM 1 was not obligated to take care of Resident 1. FM 1 stated FM 1 could not take care of Resident 1. During a telephone interview on 4/16/24 at 2:42 pm, the SSD stated per Resident 1, she (Resident 1) would be discharged home with Resident 1's family. The SSD stated when SSD reached out to Resident 1's family (unidentified), no one was available. The SSD stated Resident 1 was self-responsible and Resident 1 told the SSD that Resident 1 arranged everything herself. The SSD stated Resident 1 told the SSD that Resident 1 had everything "up there" (discharge location). The SSD stated Resident 1 told the SSD that Resident 1's family member (FM 1) was a nurse. The SSD stated the SSD offered Resident 1 everything, but Resident 1 “had it handled.” During a telephone interview on 4/16/24 at 3:03 pm, Resident 1 stated Resident 1 was in the welfare department and had nowhere to stay. During an interview on 4/16/24 at 3:35 pm, the DON and SSD were informed that Resident 1 stated Resident 1 had nowhere to stay. The DON stated the DON would call around and see if the facility had any sister facilities (any company that had close affiliations with a company with a different name that was owned by the same parent company) in the area where Resident 1 would like to be. The DON stated the DON believed Resident 1 was discharged safely because Resident 1 stated it was Resident 1's home. The SSD stated potential harm could occur to a resident (in general) if the facility did not ensure a safe discharge. During a telephone interview on 4/17/24 at 11:34 am, Resident 1 stated Resident 1 was staying in a motel and did not have a place to stay after that night. During a review of the facility's policy and procedure (PP) titled, "Discharge Planning Process," revised in 10/17, indicated the discharge planning process should include re-evaluation to identify changes with residents that required modification of the discharge plan. The PP indicated the discharge plan should be updated as necessary, to reflect any changes. The PP indicated to consider caregiver/support person availability and the resident's or caregiver's support person(s) capacity and capability to perform the required care, as part of the identification of the resident's discharge plan. The facility failed to provide a safe discharge for Resident 1. This violation resulted in Resident 1 being unsafely discharged with nowhere to stay, after being discharged 497 miles away from the facility. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.