Every finding on record at Los Robles Healthcare

The following reflects the findings of the California Department of Public Health - Licensing and Certification during an investigation of a complaint. Complaint: CA70798 - Substantiated. Representing the Department: 37886 - HFEN The inspection was limited to the investigation of the complaint and does not reflect the findings of a full inspection of the agency.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure Patient 1 received a notification of the decision to terminate services and a written copy of the discharge instructions. This failure violated the patient's rights to be informed about his care. During a record review on 6/17/22 at 11:49 AM, Patient 1’s medical record failed to document that patient 1 received notification prior to being discharged from the agency. During a phone interview on 6/17/22 at 12:51 PM with patient 1, Patient 1 was asked if she received a copy of discharge instructions from the HHA, Patient 1 stated, “I’m not seeing any letter from them. I called them for service, and they said I was discharged. I only knew because I called, and they never called and told me I was discharged. I have to have a service, I have catheter, it needs to be flushed weekly. I was told that there's not a supervisor that will speak to me. They obviously don't want to communicate with me. Because they told me I was discharged. That's the only reason I called [another agency name redacted] HHA. I don’t think I had any missed visits at the home health.” During an interview on 6/17/22 at 1:45 PM with the DPCS indicated, the discharge from home health is not MD based. We based it according to what the number of visits Medicare allows us to do. The patient was informed she is discharged. When DPCS was asked why the documented reason of patient 1’s discharged was due to non-compliance, no further information was provided by DPCS. Review of the agency’s list of discharges indicated, Patient 1 was discharged on 5/16/22 and the discharge reason was noncompliant. The agency policy and procedure titled "Discharge Criteria and Process" dated 10/2019 indicated, "...A copy of discharge instructions will be mailed to the patient. The decision to terminate or reduce services must be documented in the clinical record citing the circumstances and notification to the patient, the responsible family/caregiver or representative, and the patient's physician..."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency staff failed to ensure a patient (Patient 1) received adequate supervision and assistance to prevent a fall per plan of care when Patient 1 was not safely transferred into a wheelchair during a skilled nursing visit at home on 5/9/22. This failure resulted in patient 1 falling and sustaining a fractured right ankle. During a phone interview on 6/10/22 at 3:30 PM, Patient 1 indicated, “…I was trying to transfer from my mobility lifter to my scooter. I usually just need somebody to help me place my feet on the base of a scooter. And the lifter does all the work and so they're just guiding me. The nurse that was here told me, that it was beneath her, that it was a CNA's job, but she wasn't a CNA, she basically stood two feet away and watched me fall to the base of my scooter…” During a phone interview on 6/14/22 at 5:00 PM, LN1 stated, She [Patient 1] asked me to help transfer her and of course, it did not go well, we called 911 and they picked her up. The LN1 was queried regarding competency on transfer training, LN 1 stated, “Not recently. I’ve been working with the agency for a year. They didn’t provide training.” During clinical record review on 6/15/22 for patient 1, the Outcome and assessment information set (OASIS-data collection tool) with resumption of care 3/21/22 indicated, Patient 1’s diagnoses included but not limited to multiple sclerosis (chronic disease affecting central nervous system). The fall risk assessment indicated patient 1 was assessed at risk for fall. Concurrent review of the plan of care developed with the physician for the certification period from 3/21/22 – 5/19/22 indicated, “…Patient has severe weakness, requires total assistance with transfers and ADLs…” Concurrent review of document titled “Patient notes/messages” dated 5/9/22, the licensed nurse (LN1) indicated, “Today’s visit I did total care, attempted to transfer patient, she fell on the base of the scooter, called 911, they picked her up and put her in the scooter. Patient is very limited from MS (multiple sclerosis) and does need assistance for almost everything. Concurrent review of document titled “Skilled Observation” dated 5/9/22 from 3:00-3:55 PM, LN 1 indicated, under musculoskeletal: weakness, limited mobility, joint pain/stiffness, poor balance, grip strength unequal, chair bound, assistive device wheelchair. Goal summary included, “…The patient will be free from falls and injury during the certification period…” Concurrent review of the job description for position title: licensed practical/vocational nurse revised 10/2019 indicated, essential functions including but not limited to implement current nursing practice following a comprehensive assessment and the plan of care. Concurrent review of document titled “PT Evaluation” visit dated 3/24/22 from 12:00 – 12:45 PM, the physical therapist (PT 1) indicated in part, precautions: high fall risk, poor endurance and MS. Patient needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence. Evaluation of living situation included patient uses PWC (powered wheelchair) as mode of locomotion. Patient requires assistance with all aspects of ADLs due to longstanding MS. Goals and interventions updated during the visit included, “…Patient will safely transfer from recliner to PWC with moderate assist…” Concurrent review of annual competency assessment checklist for licensed vocational nurse indicated, the supervisor signed 5/13/22, LN1 who was hired on 5/17/21 signed the competency checklist on 6/9/22, however no self-assessment indicated.