F0627

D

Failure to Assess, Document, and Justify Hospital Transfers for ADL Decline

Torrance, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that transfers and discharges to a general acute care hospital (GACH) were medically necessary, properly assessed, and appropriately documented for two residents. For Resident 33, who had hemiplegia and hemiparesis following a cerebral infarction, contractures, end stage renal disease, muscle wasting, and atrophy, the care plan called for monitoring conditions that might contribute to ADL decline and referring to rehabilitation therapy if a decline was noted. Physician progress notes in October documented no decline in responsiveness or new confusion and instructed staff to call 911 for acute medical symptoms. Nursing notes on 12/8/2025 documented that Resident 33 was alert, oriented, able to make needs known, and refused a doctor-ordered transfer to the hospital for “further evaluation related to decrease in participation in ADLs,” with risks and benefits explained. There was no nursing documentation of an actual ADL decline or change of condition prior to the transfer.

Therapy records for Resident 33 showed that from late September through 12/10/2025, the resident received PT and OT and made gains. The OT discharge summary documented that the resident met goals for washing the face with assistance and had a Modified Barthel Index current level of functioning score of 19, exceeding the target of 18, and was discharged from OT on 12/10/2025 with documented gains. PT notes on 12/10/2025 showed improved knee extension and active participation in therapeutic exercises, and the PT discharge summary indicated discharge from PT on that date. The MDS dated 12/18/2025 showed the resident could express wants and understand verbal content, was dependent for several ADLs, used a wheelchair, and had received PT and OT in the last seven days. Interviews with the DOR and DON confirmed that Resident 33 had improved, exceeded therapy goals, and did not have a documented decline; both stated there was no medical necessity or reason for the hospital transfer, and the DOR stated that a decrease in ADLs is not a hospital diagnosis. The COC form dated 12/11/2025 was reported as blank, and LVN 5 stated there was no documentation of a change in ADLs or interventions to prevent hospitalization.

Despite the lack of documented ADL decline, Resident 33 was transferred to the GACH on 12/11/2025. The GACH face sheet listed chief complaints of end stage renal disease and elevated lipase, and hospital physician notes documented intermittent abdominal pain, intact sensation, and stable neurological status, with radiology showing nonspecific bowel gas. Facility nursing notes on readmission from the GACH indicated the resident was admitted there for abdominal pain, diagnosed with end stage renal disease and elevated lipase, and received dialysis. Resident 33 reported being transferred for three days with the expectation of receiving therapy, repeatedly asking at the hospital why she was there, and not receiving therapy after returning. Facility staff interviews (CNA 8, LVN 5, RNS 3, DOR, and DON) consistently showed that the stated reason for transfer was decreased participation in ADLs, but there was no supporting documentation of a change of condition, no documented attempts to address ADL issues in-house, and no completed COC form documenting symptoms or interventions.

For Resident 44, who had dementia, congestive heart failure, generalized muscle weakness, and bipolar disorder, the MDS indicated intact cognition and a need for partial/moderate assistance with bed mobility and lower body dressing. A COC form dated 8/27/2025 documented a decline in ADL status starting that day, with noticeable regression in physical and postural control and physician notification. The transfer form dated 8/29/2025 stated the resident was transferred to the GACH due to decline in ADL status and noted postural imbalance with right-sided leaning, raising concerns for musculoskeletal weakness or neurological involvement. However, OT treatment encounter notes on 8/26/2025 and 8/27/2025 documented that the resident actively participated and was compliant with skilled interventions, and PT encounter notes on 8/26/2025 and 8/28/2025 indicated improvement and no ADL decline.

During record review and interviews, LVN 1, the DOR, the DON, and the MDS nurse confirmed that therapy documentation for Resident 44 showed no decline in mobility or ADLs and that the resident had improved before discharge to the GACH. The MDS nurse and LVN 1 stated there were no laboratory tests or diagnostic tests ordered by the physician in response to the COC on 8/27/2025 and before the transfer on 8/29/2025. They also stated there was no documentation that the resident was monitored or that the resident was not doing well due to ADL decline between the COC date and the transfer date, and no documentation that the resident required transfer to the hospital. The DON stated she could not recall why the resident was discharged to the hospital and acknowledged that not monitoring, reassessing, and documenting the necessity of transfer after a COC had the potential to result in an inappropriate discharge.

The facility’s undated policy and procedure titled “Transfer or Discharge” required that when a transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility, the physician must document the specific needs that cannot be met, the facility’s attempts to meet those needs, and the receiving facility’s services available to meet those needs. In the cases of Resident 33 and Resident 44, the survey findings showed that the facility did not document medical necessity for transfer, did not complete or fully document COC forms, did not document monitoring or reassessment after reported changes in ADL status, and did not document attempts to meet the residents’ needs before transferring them to the GACH. These omissions led to the deficiency that residents were transferred without evidence that their needs were assessed or that the facility attempted to meet those needs prior to discharge.