Health inspection·November 4, 2021

CLASS B CITATION -- REFUSAL TO READMIT F626- 483.15 (e) (1) 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. Title 22 72521 (C) (2) - Administrative Policies and Procedures (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, rates of charge for services included in the basic rate, type of services offered, changes for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. Based on interviews and record reviews, the facility failed to: 1. Permit resident to return to the facility after hospitalization for one sampled resident (Resident 1). 2. Ensure Resident 1's medical record and the Proposed Discharge notification contained a valid basis for discharge. 3. Ensure Resident 1's medical record showed evidence that the facility made efforts to provide reason what services they are not able to provide the resident in the same facility. As a result, Resident 1 had to stay in the General Acute Care Hospital (GACH) Emergency Department from 10/28/2021 to 11/2/2021 setting for five days and admitted to the GACH inpatient from 11/2/2021 up to the present to free up beds at the GACH ED while waiting for a different Skilled Nursing Facility to accept the resident. Findings: On 11/2/2021, an unannounced visit was made to the facility to conduct a complaint investigation regarding the facility refusing to readmit Resident 1. A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on 12/24/2020 with diagnoses of type two diabetes (a chronic condition that affects the way the body processes blood sugar), post-traumatic stress disorder (a disorder that people develop after they experience or see a traumatic event), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one’s daily activities), polyneuropathy ( a disorder that involves damage to multiple peripheral nerves (nerves that branch out from the brain and spinal cord), and difficulty in walking. A review of Resident 1's History and Physical Examination form dated 2/17/2021, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 9/7/2021, indicated the resident had intact cognition. The MDS indicated Resident 1 required extensive one-person assistance during bed mobility, toilet use, dressing, and personal hygiene. The MDS indicated Resident 1 was totally dependent on two-person for transfers. A review of Resident 1's Change in Condition Evaluation (COC) Form, dated 10/28/2021 timed at 6:30 PM, indicated Resident 1 was acting differently with increased confusion and difficulty to arouse. The COC indicated Resident 1 was gagging, coughing up sputum, rocking back and forth in the chair, and repeatedly was stating “God help me.” The COC indicated that Resident 1 was unable to respond to any questions, was screaming uncontrollably, and was unable to follow or respond to the staff. The COC form indicated that 9-1-1 (a phone number used to contact the emergency services) emergency services was called at 5:25 AM. The COC form indicated Resident 1’s attending physician (MD 1) was notified on 10/28/2021 at 9 AM. A review of Resident 1’s “Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form” dated 10/28/2021 timed at 5:30 AM, indicated Resident 1 was transferred to the GACH on 10/28/2021 at 5:30 AM for altered mental status. A review of the GACH’s “Emergency Physician’s Note – Import’s” form dated 10/28/2021 timed at 6:45 AM, indicated that Emergency Physician (MD 2) examined Resident 1 and was admitted to the GACH Emergency Department (ED) on 10/28/2021 at 6:29 AM with clinical impression of altered level of consciousness (ALOC), diabetes mellitus, mild hypoxemia (a low level of oxygen [a chemical element] in the blood), and a chronic smoker. A review of the GACH’s Admitting Form dated 10/28/2021 timed at 6:46 AM, indicated Resident 1 was admitted to the GACH on 10/28/2021 at 6:29 AM with admitting diagnoses of altered level consciousness (a state of being awake and aware of one’s surroundings). A review of GACH’s Emergency Physician’s Note dated 10/29/2021 timed at 11:30 PM, indicated Resident 1 was still boarded in the GACH ED and waiting placement to a Skilled Nursing Facility. The Note indicated that Resident 1 was in no acute distress and resting and had remained stable during the night shift. A review of the GACH Emergency Physician’s Note dated 11/1/2021 timed at 11:30 PM, indicated that Resident 1 was still boarded in the GACH ED and waiting placement to a different Skilled Nursing Facility because Resident 1 was not accepted back by the originating Skilled Nursing Facility. The GACH ED Note indicated Resident 1’s diagnosis was substance abuse. A review of the GACH’s Social Worker (SW) Note dated 10/28/2021 timed at 2:54 PM, indicated that the facility’s Director of Admissions stated that Resident 1 cannot return to the facility because there was no bed hold, Resident 1’s non-compliance with the facility policy, and the resident putting herself at risk, and other residents in the facility at risk. The GACH SW note indicated that GACH SW 1 notified the facility’s Director of Admissions that Resident 1 did not have an eviction notice and there was a bed hold for the resident, according to the insurance company. The SW note indicated that the facility’s Administrator contacted GACH SW 1 and explained that the facility would not accept Resident 1 back due to resident’s “illegal behavior.” GACH SW Note indicated that according to the facility Administrator, Resident 1’s behavior had been going on for three to four months. GACH SW Note indicated that the facility Administrator notified GACH SW Note that the facility staff would come to the GACH that day (10/28/2021) to give Resident 1 the eviction notice. GACH SW Note indicated that Resident 1 was upset that the facility did not want to take her back. A review of GACH’s Social Worker (SW) Note dated 10/29/2021 timed at 3:59 PM, indicated that SW 1 notified the facility’s Director of Admissions of having difficulty finding a placement (discharge destination) for Resident 1. The GACH SW Note indicated that the facility’s Director of Admissions would assist GACH SW 1 with finding placement for Resident 1. During a joint interview with the facility Administrator and the facility Operator/Owner on 11/2/2021 at 11:28 AM, Administrator stated the facility received call from the GACH on 10/28/2021 and the facility notified the GACH that the facility would not be accepting Resident 1 back because the resident committed a “felony (offense).” The Administrator stated during the facility’s cleaning of Resident 1’s room, the facility staff found glass pipes (a smoking tool for smoking tobacco or herb) with some burned residue inside, two “M&M” (plastic storage container) containers filled with marijuana (psychoactive [mind altering] chemical), and glass igniters (a device used to initiate combustion). The Administrator stated they notified the police department immediately. The Administrator stated Resident 1 was transferred to the GACH on 10/28/2021, because of being not alert and oriented. The Administrator stated Resident 1 had an out-on-pass order for doctor’s appointments. The Administrator stated Resident 1 refused to give consent for the inventory check. During an interview on 11/2/2021 at 11:57 AM, the Director of Nursing (DON) stated that on 10/28/2021, the facility called 9-1-1 emergency services because Resident 1 was different and not her normal self and was yelling “God help me, god help me.” DON 1 stated Resident 1 was sent to the GACH via 9-1-1 emergency services for suspected drug abuse. During a telephone interview with the facility administrator on 11/2/2021 at 4:10 PM, the Administrator stated that the police could not arrest or take Resident 1 to police custody because the drug paraphernalia was not in Resident 1’s possession at the time of the police search because the resident was already transferred to the GACH. During a telephone interview with the GACH SW 2 on 11/2/2021 at around 4:30 PM, GACH SW 2 stated that Resident 1 had physician’s orders to be transferred back to the facility on 10/28/21 at around 11:28 AM. GACH SW 2 stated that Resident 1 stayed in the GACH ED from 10/28/2021 to 11/2/2021 waiting for discharge placement because the facility would not readmit the resident back. GACH SW 2 stated that GACH SW 2 had talked to MD 2 to just admit Resident 1 to the GACH Inpatient on 11/2/2021, because the GACH needed beds available from the ED. GACH SW 2 also stated that Resident 1 was diagnosed with ESBL of urine and now needing an isolation room for transmission-based precautions. GACH SW 2 stated that Resident 1 is now harder to find placement because of the need for a private room. GACH SW 2 stated that according to MD 2, since Resident 1 did not have fever, the white blood cells (WBC) were normal, and did not have other physical symptoms of infection, Resident 1 did not need to stay in the GACH. GACH SW 2 stated that according to MD 2, Resident 1 can be discharged back to a skilled nursing facility level of care. GACH SW 2 stated that Resident 1’s current condition was stable now, very quiet, and denied consuming illegal drugs, however admitted to smoking marijuana. GACH SW 2 stated Resident 1’s current condition and behavior currently did not pose a danger to self and others. GACH SW 2 stated that the facility’s Director of Admissions informed the GACH SW 1 that the facility was “not afraid to pay the fine.” During a telephone interview, with the facility Administrator on 11/2/2021 at 4:45 PM, the Administrator stated the facility was assisting the GACH to find another Skilled Nursing Facility or Assisted Living Facility (a senior living option for those with minimal needs for assistance with daily living and care) that can take Resident 1 from GACH. The Administrator stated she would not readmit Resident 1 back to the facility while waiting to find an appropriate discharge destination and another facility to accept the resident. During a telephone interview, on 11/4/2021 at 11:18 AM, the facility Administrator stated that on 10/28/2021, the facility’s census was 46 with two open female beds and 10 open male beds. The facility Administrator stated the facility keep one room open for an isolation room reserved for the facility’s possible Red Zone (an area where COVID 19 positive residents are housed). The Administrator stated the census for 11/4/2021 was 46 with one open female bed and 10 open male beds. A review of the facility document titled “Bed-Hold Agreement,” with bed hold completed upon the admission portion initially signed by Resident 1 on 12/24/2020, indicated that Resident 1 was informed of her right to hold the bed for 7 days if the resident is transferred to a general acute care hospital or goes on a therapeutic leave. The facility document with the portion for “Notification of Bed Hold option upon transfer/therapeutic leave” signed by a facility representative (Registered Nurse 1) dated 10/28/21 timed at 5:30 am, indicated Resident 1 could not sign because due to “Altered level of consciousness.” A review of Resident 1’s Notice of Proposed Transfer and Discharge, dated 10/28/2021, indicated that discharge notification was sent to the resident via SMS (a text messaging service) to the resident’s mobile phone. The form indicated Resident 1’s effective discharge date was 10/28/2021 and the discharge reasons indicated “the safety of individuals in the facility ins endangered by your presence due to clinical/behavioral status and “the health of individuals in the facility is endangered by your presence.” The form indicated that Resident 1 was informed by telephone and hard copy faxed after consenting with the resident. A review of the facility's policy and procedure titled "Transfer and Discharge," revised in November 2016, indicated the facility should ensure that adequate preparation and assistance is provided to the resident prior to discharge from the facility. The facility failed to: 1. Permit resident to return to the facility after hospitalization for one sampled resident (Resident 1). 2. Ensure Resident 1's medical record and the Proposed Discharge notification contained a valid basis for discharge. 3. Ensure Resident 1's medical record showed evidence that the facility made efforts to provide reason what services they are not able to provide the resident in the same facility. As a result, Resident 1 had to stay in the General Acute Care Hospital (GACH) Emergency Department from 10/28/2021 to 11/2/2021 setting for five days and admitted to the GACH inpatient from 11/2/2021 up to the present to free up beds at the GACH ED while waiting for a different Skilled Nursing Facility to accept the resident. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.