Health inspection·February 7, 2025

§ 72520. Bed Hold. (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. § 72521. 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 patient 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. (3) Policies and procedures for admission or discharge of a patient which state that a patient shall not be admitted or discharged based on race, color, religion, ancestry, national origin, sexual orientation, disability, medical condition, marital status, or registered domestic partner status, except: F626- §483.15(e)(1) Permitting patients to return to facility. A facility must establish and follow a written policy on permitting patients to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A patient, 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 patient— (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. An unannounced visit was conducted by California Department of Public Health on 1/28/2025 at 9:30 AM to investigate a facility reported incident regarding an allegation of not readmitting seven residents back to the facility after the Facility 1 was cleared to repopulate (transfer back residents to the facility from the previous temporary location when residents were evacuated) on 1/17/2025 after an emergency evacuation on 1/8/2025 due to a local fire. The facility failed to readmit Patients 1, 2, and 3 on 1/17/2025 when patients were cleared to repopulate back to Facility 1, after being evacuated by city officials on 1/8/2025 due to a local fire. This deficient practice resulted in: 1. Patient 1 residing at Facility 2 from 1/17/2025 to 2/7/2025 (22 days) without the knowledge and consent from the patient’s responsible party (RP-an individual, or a placement agency, who assists the patient in placement or assumes varying degrees of responsibility for the well-being of the patient, as designated by the patient in writing) to permanently place patient at Facility 2. 2. Patient 2 residing at Facility 2 from 1/17/2025 to 2/7/2025 (22 days) without the knowledge and consent from the patient’s conservator (an appointed person to act or make decisions for the person who needs help) to permanently place the patient at Facility 2. 3. Patient 3 resided at Facility 2 from 1/17/2025 to 1/22/2025 and residing at Facility 3 from 1/22/2025 to 2/7/2025 (22 days) without the knowledge and consent from her RP to permanently place the patient at Facility 3. This placed Patients 1, 2, and 3 at risk for psychosocial harm and compromised continuity of care. 1. A review of Patient 1’s Admission Record (from Facility 1), indicated Patient 1 was a 91-year-old female, admitted at Facility 1 on 11/26/2024 with diagnosis of dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities). A review of Patient 1’s Minimum Data Set (MDS- a standardized patient assessment and care screening tool) dated 12/2/2024, indicated Patient 1 had moderate cognitive impairment (inability to think, learn, remember, or make decisions). The MDS indicated Patient 1 required supervision (helper provides verbal cues and or touching as patient competes activity. Assistance may be provided throughout the activity or intermittently) for toileting, bathing, lower body dressing, personal hygiene, rolling left and right, sitting on the side of the bed to lying flat on the bed, sitting up, and transferring from a bed to a chair. A review of Patient 1’s Physician’s Discharge Summary, undated and unsigned by a physician, indicated Patient 1 was transferred to Facility 2 on 1/8/2025 due to emergency evacuation. During an interview on 1/27/2025 at 11:30 AM with Administrator 2 at Facility 2, Administrator 2 stated the Facility 1 had taken back some of the patients that were evacuated, and only two patients (Patient 1 and 2) remained at Facility 2, but the plan was for them (Patients 1 and 2) to go back to the facility once the facility was cleared for patients to repopulate. During a concurrent observation and interview on 1/27/2025 at 11:45 AM with Patient 1, in Facility 2’s dining room, Patient 1 stated she is waiting to go back to the Facility 1 but has not been informed nor asked if she desires to return to Facility 1. During an interview on 1/28/2025 at 9:30 AM with Administrator 1 (administrator of the facility), Administrator 1 stated Patient 1 was evacuated to Facility 2 on 1/8/2025 and that Facility 2 was a better fit for the patient and therefore Patient 1 would not return Facility 1. During an interview on 1/28/2025 at 10:20 AM with Licensed Vocational Nurse (LVN- licensed nurse from the facility), LVN stated Facility 1 was responsible for notifying patient’s responsible party, if the patients had any cognitive impairment regarding transfers and discharges, and other necessary information that requires consent. LVN stated the reason Patient 1 was not readmitted back to Facility 1 was because LVN did not think it was safe for Patient 1 to reside Facility 1 due to Patient 1 being older, and because LVN thought Facility 2 was a better fit for Patient 1. LVN stated the facility did not inform and get consent from Patient 1’s RP’s and interdisciplinary team regarding Patient 1 not coming back to Facility 1. During a phone interview on 1/28/2025 at 10:49 AM with Patient 1’s RP, the RP stated she had not been notified about Patient 1 not being able to return Facility 1, and RP stated she wants her mom (Patient 1) to be transferred Facility 1 because she does not want her mom to stay at Facility 2. 2. A review of Patient 2’s Admission Record (from Facility 1), indicated Patient 2 was a 69-year-old female, admitted at Facility 1 on 1/1/2014 with diagnosis of intellectual disabilities (a lifelong condition that affects a person’s ability to learn, communicate, and perform daily tasks), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), encephalopathy (disease of the brain that alters brain function or structure) disturbance of brain function, it causes confusion, memory loss and coma in severe cases), and dementia. A review of Patient 2’s MDS, dated 12/7/2024, the MDS indicated Patient 2 had severely impaired cognition (ability to think, learn, and make decisions). The MDS indicated Patient 2 was dependent (helper does all of the effort, patient does none of the effort to complete the activity) on staff for toileting, bathing, dressing, personal hygiene, and required maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for oral hygiene, roll left and right, sit to lying, sit to stand, and chair/bed transfer. A review of Patient 2’s Physician’s Discharge Summary, undated and unsigned by a physician, indicated Patient 2 was transferred to Facility 2 on 1/8/2025 due to emergency evacuation. During an interview on 1/28/2025 at 10:25 AM with LVN, LVN stated Patient 2 was not readmitted back to Facility 1 from 1/17/2025 until today (1/28/2025). LVN stated the facility did not inform and get consent from Patient 2’s RP to have Patient 2 permanently admitted at Facility 2. During an interview on 1/28/2025 at 10:42 AM with the Director of Nursing (DON) from the facility, stated she was not part of the decision-making process to determine if the patients (Patient 1, 2, and 3) who were evacuated were to return to Facility 1 after Facility 1 was cleared to repopulate on 1/17/2025. During a phone interview on 1/28/2025 at 11:05 AM with Patient 2’s RP, the RP stated she could not find any documentation regarding notification that Patient 2 would not return to Facility 1. RP stated Administrator 1 had left a voicemail stating Facility 1 would not take Patient 2 back because the patient “causes a lot of problems and the staff is exhausted” and the RP stated, RP never gave consent for that decision. 3. A review of Patient 3’s Admission Record (from Facility 1), indicated Patient 3 was an 84-year-old female, admitted to Facility 1 on 12/23/2024 with diagnosis of encephalopathy, dementia, and Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). A review of Patient 3’s MDS, dated 12/30/2024, the MDS indicated Patient 3 had intact cognition. The MDS indicated Patient 3 required partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) on staff for toileting, bathing, dressing, roll left and right, sit to lying, sit to stand, and chair/bed transfer. A review of Patient 3’s Physician’s Discharge Summary, undated and unsigned by a physician, indicated Patient 3 was transferred to Facility 2 on 1/8/2025 due to emergency evacuation.   During an interview on 1/28/2025 at 10:29 AM with LVN, LVN stated the reason Patient 3 was not readmitted back to Facility 1 was because LVN believed it was not safe for Patient 3 to be at the facility due to the patient’s older demographic, since currently the facility had a younger demographic. LVN stated Facility 1 did not inform Patient 3’s RP that Patient 3 would not be coming back to Facility 1. During a phone interview on 1/28/2025 at 12:37 PM with Patient 3’s RP, RP stated she had not been notified by Facility 1 that Patient 3 would not be returning. RP stated she found out Patient 3 was moved to Facility 2 and from Facility 2, the resident was moved to Facility 3 on 1/22/2025. RP stated it was Facility 2 who contacted the RP to inform RP that Patient 3 had been transferred to Facility 3 on 1/22/2025. RP stated, currently, Patient 3 resides at Facility 3, and RP wanted Patient 3 to go back to Facility 1 where the patient was evacuated from. During an interview on 1/27/2025 at 1:05 PM with the DON 3 (DON of Facility 3), stated she had Patient 3 from Facility 1 and had not been informed by Facility 1 staff if or when the patient would be returning to the Facility 1 where resident was evacuated from. The DON 3 stated she had not been informed why Patient 3 was still at Facility 3, nor if the patient chose to stay at Facility 3. A review of the facility’s census dated 1/27/2025 indicated the facility had 12 beds available. During a review of the facility 1’s policy and procedure titled “Transfer or Discharge Notice”, dated December 2016, the policy indicated the patient and/or representative will be notified in writing of the following information: a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the patient is being transferred or discharged. d. A statement of the patient’s rights to appeal the transfer or discharge, including: (1) the name, address, email and telephone number of the entity which receives such requests. (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process. The policy further indicated the reasons for the transfer or discharge will be documented in the patient’s medical record. At the time of notification, the facility will provide each patient and responsible party with the following information: a. The plan for the transfer and adequate relocation of the patient. b. The date by which the transfer/relocation will be completed; and c. Assurances that the patient will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, service and location. In determining the transfer location for a patient, the decision to transfer to a particular location will be determined by the needs, choices and best interests of that patient. During a review of the facility’s policy and procedure titled “Admission Criteria”, dated March 2019, the policy indicated prior to admission, the patient or representative is informed of any service limitations or special characteristics of the facility. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential patient that are outlined in the evaluation. The facility failed to readmit Patients 1, 2, and 3 on 1/17/2025 when patients were cleared to repopulate back to the Facility 1, after being evacuated by city officials on 1/8/2025 due to a local fire. This placed Patients 1, 2, and 3 at risk for psychosocial harm and compromised continuity of care. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1, 2, and 3.