Health inspection·March 1, 2024

The following reflects the findings of the California Department of Public Health during the investigation of two complaint number CA00881231. Representing the Department, Health Facility Evaluator Nurse # 36395 A Class B State citation was written. 42 CFR §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— 22 CCR § 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. On 1/24/24, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about Admission, Transfer, and Discharge Rights. The facility failed to permit Resident 1 to return to the facility on 1/19/24, after hospitalization, when ready for discharge from General Acute Care Hospital 2 (GACH 2). As a result, Resident 1 experienced an unnecessarily prolonged hospitalization while GACH 2 found new placement. Resident 1’s right to return to the facility was violated and Resident 1 was readmitted to the facility on 1/31/2024. During a review of the Admission Record indicated the facility admitted Resident 1 on 9/22/23 with diagnoses including morbid obesity (more than 80 to 100 pounds [lbs., unit of measurement] of their ideal body weight) and chronic obstructive respiratory disease (COPD, group of diseases that cause airflow blockage and breathing related problems). During a review of the Minimum Data Set (MDS, standardized care and screening tool) dated 9/25/23, indicated Resident 1 was cognitively intact (mental process involved in knowing, learning, and understanding). Resident 1 needed two-person physical assistance with eating, personal hygiene and three-person physical assistance with bed mobility, dressing, toilet use and bathing. During a review of the Situation Background Communication Form (SBAR, communication tool that share information among healthcare team about resident condition) and Progress Note dated 12/14/23 at 10:45 a.m., indicated Resident 1 was transferred to GACH 1 on 12/14/23 due to altered mental status (AMS, abnormal state of alertness or awareness). Resident 1 was drowsy and lethargic (decrease in consciousness). The paramedics were called and transferred Resident 1 to GACH 1. During a review of the GACH 2 Inpatient Admission Face Sheet (a document that gives a patient’s information at a quick glance) indicated Resident 1 was transferred from GACH 1 to GACH 2 on 1/3/24 at 2:38 p.m. During a review of the GACH 2 Discharge Plan Treatment Team Communication dated 1/19/24 at 3:06 p.m., indicated the GACH 2 case manager (CM) called the facility and informed the facility that Resident 1 was ready to return to the facility. The facility informed the CM that Resident 1 was “… off bed hold and will not accept patient (Resident 1) back.” During a review of the GACH 2 Discharge Plan Treatment Team Communication dated 1/22/24 at 3:27 p.m., indicated the GACH 2 CM called the facility, and the facility informed the CM that Resident 1 “…was out of bed hold and has no bed available”. During an interview on 1/24/24 at 9:06 a.m., the director of nursing (DON) stated, “There is no available bed for [Resident 1]”. DON stated Resident 1 was already discharged and it was already a month since Resident 1 was discharged. DON stated the facility was unable to provide the needs of Resident 1, “… He was not satisfied with our service. If we accept him, he will be unhappy and will have a lot of complaints.” DON further stated, “I’d rather pay the fine than accept the patient (Resident 1) back”. During an interview on 1/24/24 at 9:41 a.m., the admission coordinator (AC) stated he received a call from GACH 2 that Resident 1 was ready to return to the facility. AC stated there was no available bed for Resident 1 at this time. AC further stated Resident 1 passed the seven-day bed hold and he was gone for more than 30 days. During a review of the facility’s policy and procedures titled “Readmission to the Facility” reviewed on 1/27/23 indicated residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. A Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold allowed by the stated will be readmitted to the facility upon the first availability in a semi-private room if the resident: a. Requires the services provided by the facility. b. Meets the admission criteria as outlined in facility policy. c. Was not discharged for any reason outlined in the Transfer or Discharge policy and d. Is eligible for Medicaid nursing facility services. The same Policy indicated residents who are not receiving Medicaid benefits will be readmitted to the facility upon the first availability of a bed is the resident: a. Needs care and medical treatment that can be provided by the facility. b. Was not discharged for non-payment of services and c. Was not discharged because of behavior problems.” The facility failed to permit Resident 1 to return to the facility on 1/19/24, after hospitalization, when ready for discharge from General Acute Care Hospital 2 (GACH 2). As a result, Resident 1 experienced an unnecessarily prolonged hospitalization while GACH 2 found new placement. Resident 1’s right to return to the facility was violated and Resident 1 was readmitted to the facility on 1/31/2024. The above violation had a direct relationship to the health, safety, and security of Resident 1.