F0627

D

Failure to Honor Right to Return and Follow Transfer/Discharge and Bed-Hold Requirements

Stockton, California Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor a resident’s right to return following a transfer to the emergency room and to follow required transfer/discharge and bed-hold procedures. The resident had been admitted in 2025 with traumatic subarachnoid hemorrhage, unspecified intracranial injury, dementia, cognitive decline secondary to traumatic brain injury, and anxiety, and was documented as his own responsible party. Staff, including the SSD, DOR, CNA, and LN, consistently described the resident as friendly, approachable, and generally without behavioral issues, though he sometimes repeated himself and could be confused. A BIMS score of 13 indicated he was cognitively intact prior to the transfer. The resident was involved in resident-to-resident altercations on two dates, with documentation on 1/1/26 of a physical altercation and on 1/5/26 of an incident in which another resident struck him multiple times in the face, causing swelling to his left wrist and lower left eye.

Following the 1/5/26 altercation, the resident was sent to the hospital for evaluation. The Administrator stated that at the time the resident was sent to the emergency room, it was considered a transfer with the expectation that he would return to the facility. However, after the Administrator’s investigation of the incident and review with the team, it was decided that the resident would be discharged from the facility and admitted to a sister facility, with the Administrator calling the hospital to inform them of this plan. The Administrator confirmed that the discharge was facility-initiated and that the stated reason was that the resident’s safety was endangered by his own presence in the facility due to the continued presence of the other resident involved in the altercations. The Administrator also confirmed that the resident was not endangering the safety of others. The facility’s own transfer/discharge policy listed limited, specific reasons for facility-initiated discharge, including when the resident’s needs cannot be met, when the resident’s health has improved, when the resident endangers the safety or health of others, nonpayment, or facility closure; the documentation did not show that any of these criteria were met in this case.

The facility also failed to provide required notices and documentation associated with the transfer and discharge. The Administrator acknowledged that she did not discuss the transfer to the sister facility with the resident, even though he was listed as his own responsible party. The Representative Payee confirmed she was not notified about the transfer and clarified that she was only responsible for financial decisions, not healthcare decisions. Review of the electronic medical record showed no physician note regarding the resident’s discharge from the facility, and no physician documentation of needs that could not be met by the facility, what was attempted to meet those needs, or what needs the accepting facility could meet that the current facility could not. Although there was a physician order allowing a seven-day bed hold, the Administrator confirmed that a bed-hold notice was not given to the resident, despite the facility’s bed-hold policy requiring written information about bed-hold practices at the time of transfer or within 24 hours in an emergency. As a result of these actions and omissions, the resident was inappropriately discharged to a sister facility after an emergency room visit and was not afforded the right to return to his original facility following the transfer.