Health inspection·March 25, 2025

California Code of Regulations, Title 22, Section § 72520. Bed Hold. (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. Code of Federal Regulations, Title 42 §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. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. On 2/11/2025 at 12:09 PM, an unannounced visit was made to the facility to investigate a complaint regarding an allegation of readmit a resident back to the facility. The facility failed to ensure Patient 1, is readmitted back to the facility on the first available bed, in accordance with the facility’s policy and procedure titled “Bed-Holds and Return,” and the “California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities”. Patient 1 was transferred from the Skilled Nursing Facility (SNF 1) to a General Acute Care Hospital (GACH) 1 on 2/04/2025 for further evaluation of Candida Auris (CRS) and was medically stable to be discharged back to the SNF 1 on 2/05/2025 but SNF 1 refused to readmit Patient 1 back to the facility. Patient 1 had to stay in the GACH for additional seven (7) days (from 2/05/2025 to 2/11/2025) and was discharged home on 2/12/2025 with home health (medical care delivered in the patient's home, if you are homebound while recovering from an illness, surgery or injury or have a chronic medical condition.). As a result, Patient 1 was not allowed to be readmitted back to the facility after the facility transferred Patient 1 to GACH 1. This deficient practice resulted to Patient 1 incurring extra seven days of unnecessary acute hospital stay at GACH 1, from 2/5/2025 to 2/11/2025. A review of Patient 1’s Admission Record (AR) indicated a 55 year old, male patient, admitted to the facility on 1/31/2025 with diagnoses that included but not limit to pyothorax without fistula (a condition where pus accumulates in the space between the lungs and chest wall), acute respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen). A review of Patient 1’s History and Physical [H&P] dated 2/03/2025, the H&P indicated the Patient has the capacity to understand and make decisions A review of Patient 1’s Change of Condition (COC) dated 2/4/2025, the COC indicated Patient 1 started receiving intravenous antibiotics that included Fluconazole 800 milligrams (a unit of measure-mg) Intravenous (IV) once a day until 2/14/2025 & Meropenem (injection used to treat infections caused by bacteria) 2 gm (a unit of measurement) 3 times a day until 2/7/2025 for Aspiration Pneumonia. Patient 1’s Primary Physician ordered to transfer Patient 1 to GACH for further evaluation (involves a systematic process to understand its nature, progression, and potential treatments, encompassing diagnosis, assessing the impact, and evaluating interventions) of Candida Auris (C. Auris-a species of fungus that grows as yeast). A review of Patient 1’s Telephone order, dated 2/04/2025 timed at 6:12 PM, the physician order indicated to transfer Patient 1 to GACH for further evaluation of Candida Auris. A review of Patient 1’s Bed Hold Agreement dated 1/31/2025 indicated “The facility had a bed hold policy and will hold the bed for up to seven (7) days if the Patient is transferred to a general acute care hospital. Patient 1’s admission Bed Hold Agreement indicated Patient 1 and a facility representative signed on 1/31/2025. A review of Patient 1’s Consent to Treatment indicated Patient 1’s name and Date of Admission as 1/31/2025. The form was signed by the Patient and facility representative and dated 1/31/2025. A review of Patient 1’s Bed Hold Agreement dated 2/4/2025 indicated Notification of bed hold upon transfer/therapeutic leave indicated Patient 1 was transferred to GACH 1 on 2/4/2025 at 10:00 pm. A review of Patient 1’s Physician Discharge Summary indicated Admission date 1/31/2025 and discharge date 2/4/2025. The Discharge Summary indicated Patient 1’s disposition as “Hospital”. A review of a facility document titled “Daily Census,” dated 2/04/2025, the Daily Census indicated Patient 1 in a room with 2 beds. The Daily Census Bed A as “empty” and indicated in Patients 1’s status “hospital paid leave” A review of a facility document titled “Daily Census,” dated 2/05/2025, the Daily Census indicated Patient 1 room Bed A as “occupied by Patient 2” and indicated in Patients 1’s status “hospital paid leave” A review of a facility document titled “Daily Census,” dated 2/06/2025, the Daily Census indicated Patient 1 room Bed A as “empty” and indicated in Patients 1’s status “hospital paid leave” A review of a facility document titled “Daily Census,” dated 2/07/2025, the Daily Census indicated Patient 1 room Bed A as “empty” and indicated in Patients 1’s status “hospital paid leave” A review of a facility document titled “Daily Census,” dated 2/08/2025, the Daily Census indicated Patient 1 room Bed A as “occupied by Patient 3” and indicated in Patients 1’s status “hospital paid leave” A review of a facility document titled “Daily Census,” dated 2/09/2025, the Daily Census indicated Patient 1 room Bed A as “occupied by Patient 3” and indicated in Patients 1’s status “hospital paid leave” A review of a facility document titled “Daily Census,” dated 2/10/2025, the Daily Census indicated Patient 1 room Bed A as “occupied by Patient 3” and indicated in Patients 1’s status “hospital paid leave” A review of a facility document titled “Daily Census,” dated 2/11/2025, the Daily Census indicated Patient 1 room Bed A as “occupied by Patient 3” and indicated in Patients 1’s status “hospital paid leave” During an interview on 2/11/2025 at 9:48 AM with GACH 1 Case Manager (GCM), GCM stated the facility admitted Patient 1 on 1/31/2025. GACH 1’s CM stated the facility discharged Patient 1 on 2/4/2025 and transferred him back to GACH 1 via non-emergency ambulance services and refused to take Patient 1 back to the facility when Patient 1 was ready to be discharged on 2/5/2025. GCM stated he and his coworker CM contacted the facility on 2/5/25, 2/6/258 and 2/7/25 and spoke to facility Case Manager, facility Marketing Director, and Licensed Vocational Nurse (LVN 1)1 who all stated the facility would not be taking Patient 1 back to the facility due to Patient 1’s diagnosis of C. Auris. GCM stated the facility was aware prior to admitting Patient 1 of his C. Auris diagnosis and choose to accept him, all of Patient 1’s clinical information was sent to the facility prior to admission for the facility to review. GCM stated facility Marketing Director stated the facility would not take Patient 1 back because they did not have a single room to accommodate him. GCM stated Patient 1 required Intravenous Antibiotics to be administered and ongoing Skilled Rehabilitation therapy that could be provided at the skilled nursing facility and did not require any additional hospital services that is why he was discharged to the facility on 1/31/2025. During an interview on 2/11/2025 at 10:50 AM with Patient 1, Patient 1 stated on 2/4/25 in the afternoon a nurse from the facility came to his room and told him the facility was going to send him back to the hospital because, “What he had was not what they thought he had”. Patient 1 stated he assumed it was about a disease, but the facility nurses did not explain any further when he asked why the facility nurse told him she had no idea, but he could either be transferred to GACH 1 or they could let him go from the facility. Patient 1 stated he felt angry because the facility was kicking him out on the street and did not give him a choice or explanation. During an interview on 2/11/2025 at 12:09 PM with Administrator (ADM), ADM stated Patient 1 was transferred back to GACH 1 because the information the facility had received from GACH 1 prior to admission did not coincide with the information they received after admission. ADM stated they thought Patient 1 would be able to cohort with another Patient but due to his diagnosis he was not able to cohort, and they could not keep him in the facility. During an interview on 2/11/2024 at 12:27 PM with Infection Preventionist Nurse (IPN), IPN stated on 2/4/2025 she was reviewing Patient 1’s GACH Faxed record when she noticed the section where is said “” IPN stated she was confused with the C. Auris diagnosis and asked the Nurse Practitioner (NP) to review with her. IPN stated then the NP wrote the order to transfer Patient 1 for further evaluation of C. Auris. IPN stated there was no specific needs Patient 1 needed that could not be met at the facility other than understanding the medical information and information on how long the isolation needed to be for Patient 1’s diagnosis of C. Auris. IPN stated the facility was able to care for patients with a diagnosis of C. Auris but if there was no other patient currently in the facility with same diagnosis the patient would not be able to share a room with other patients. During a concurrent interview and record review on 2/11/2025 at 12:45 with IPN, IPN stated the Patient 2 who had been admitted to the facility on 2/5/2024 did not have any medical condition that required isolation (separates sick people with a contagious disease from people who are not sick). During a telephone interview on 2/11/2025 at 2:21 PM with Director of Nursing (DON), the DON stated he completed the pre- admission inquiry for Patient 1 and notified the Facility Marketing Director that the facility was able to admit Patient 1. The DON stated he did not notice the preadmission inquiry included Patient 1’s diagnosis of C. Auris. The DON stated after the facility admitted Patient 1 the NP decided to transfer Patient 1 back to GACH due to GACH not disclosing Patient 1 diagnosis of C. Auris before admission. The DON stated he was not aware GACH was trying to transfer Patient 1 back to the facility until today (2/11/2025). DON stated the facility was able to provide care for a Patient with a diagnosis of C. Auris and Patient 1 was on a 7-day bed hold which allowed him to return back to the facility. During a telephone Interview on 2/11/2025 at 3:13 PM with Facility Marketing Director (FMD), the FMD stated the facility received the initial Quick check Inquiry Form request for admission for Patient 1 in January he sent the documents to DON for review. DON responded that the Patient was ok to be admitted to the facility. FMD stated after Patient 1 ‘s admission to the facility, it was made aware to the facility that Patient 1 was diagnosed of C. Auris. The FMD stated he met with the Interdisciplinary team (team consisting of ADM, DON, Case manager) to review the facility census and found that facility do not have any other Patients with same diagnosis of C. Auris that able to share a room with Patient 1. They could not afford to accommodate Patient 1 with a single room and decided to transfer him back to the GACH. FMD stated GACH CM contacted him various times and on various days asking for the facility to take Patient 1 back, but he informed them the facility would not take Patient 1 back. A review of the facility’s policy and procedure (P&P) titled Bed Hold with a revision date of July 2017 indicated “Purpose-To ensure that the Patient and/or his/her representative is aware of the facility’s bed-hold policy, and that such policy complies with State and federal laws and regulations. The policy further indicated. The licensed Nurse will ask the attending physician to determine the Patient’s projected length of stay in the acute care hospital. The licensed nurse will write the approximate length of stay in the acute care hospital on the Physicians order sheet for the bed hold, The licensed nurse will communicate with acute care hospital staff to monitor the Patient’s medical progress and expected date of return to the facility. The facility failed to ensure Patient 1, is readmitted back to the facility on the first available bed, in accordance with the facility’s policy and procedure titled “Bed-Holds and Return,” and the “California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities”. Patient 1 was transferred from the Skilled Nursing Facility (SNF 1) to GACH 1 on 2/04/2025 for further evaluation of Candida Auris (CRS) and was medically stable to be discharged back to the SNF 1 on 2/05/2025 but SNF 1 refused to readmit Patient 1 back to the facility. Patient 1 had to stay in the GACH for additional 7 days (from 2/05/2025 to 2/11/2025) and was discharged home on 2/12/2025 with home health. As a result, Patient 1 was not allowed to be readmitted back to the facility after the facility transferred Patient 1 to GACH 1. This deficient practice resulted to Patient 1 incurring extra seven days of unnecessary acute hospital stay at GACH 1, from 2/5/2025 to 2/11/2025. This violation had a direct or immediate relationship to the health, safety, and security of Patient 1.