The patient's family member had no training in transfers or mobility assistance and couldn't lift the resident from bed or provide shower care. The wheelchair was too heavy to maneuver, and there were no bed rails or assistive devices at home.
Bayshire San Dimas Post-Acute admitted the resident on May 20, 2024, following a stroke that caused paralysis and weakness on her right side, speech difficulties, and muscle wasting. She required substantial assistance with oral hygiene, dressing, and personal care, and was dependent on staff for bathing, toileting, and mobility.
The facility's discharge summary, dated July 9 at 2:32 PM, stated that home health services had been arranged with a specific agency, including nursing, physical therapy, and occupational therapy. The document indicated no medical equipment was needed and no outpatient therapy services were arranged.
But the Social Services Director later admitted to state inspectors that she had documented the home health arrangements before actually securing them. After the patient left the facility, every home health agency contacted denied services.
The family received less than three hours' notice of the discharge. The patient's representative told inspectors that the insurance company called the facility at 2:20 PM on July 9 to inform them coverage would end that day. Rather than pay $350 per day out of pocket, the family picked up the patient at 5:40 PM.
"It came as a total surprise," the family member said. "I did not think she was ready for discharge from the facility."
The family member described the impossible situation at home: "I had no help at home. I did not know how to lift or transfer her from the bed. There were no bed rails or any assistive device at home, and her wheelchair was so heavy. I could not shower her and could only change her diaper while she was in bed."
No home health visits materialized. The family member, who had her own medical issues, struggled to obtain the patient's medications and had to resolve problems with finding a new primary care physician.
The facility's Rehabilitation Director visited the patient's home five days after discharge and found conditions unsafe for the level of care needed. The shower chair didn't fit in the shower area. The patient needed a hemi-walker for stability, which was safer than the cane she had. The family member's difficulty with bending made it impossible to assist with transfers and walking.
"When home health services were not arranged as ordered, Resident 2 had a potential to decline and was at an increased risk for deconditioning," the Rehabilitation Director told inspectors.
The Director of Nursing acknowledged during the inspection that the facility "did not arrange the home health services prior to Resident 2's discharge from the facility" and "must follow the discharge order and maintain continuity of care to ensure Resident 2's safe discharge."
The Social Services Director revealed the sequence of events that led to the failed discharge. She learned on July 8 that the patient's insurance coverage would end July 7, so she submitted medical documentation requesting an extension. On July 9, the insurance company denied the extension and said coverage had ended July 8, requiring discharge that day to avoid out-of-pocket costs.
Because of the short notice, she documented that home health services were arranged based on the facility's relationship with one agency. Only after the patient left did she call multiple agencies, all of which denied services. She called the insurance company's case manager, who promised to send outpatient rehabilitation resources, but provided no updates through the date of inspection nine days later.
The home health agency listed in the discharge paperwork told inspectors they never received a referral for the patient.
The Social Services Director admitted she made only phone calls to arrange services and "did not document the HHA referrals or the phone calls she made in Resident 2's electronic health records." She acknowledged that safe discharge required ensuring patients had necessary equipment at home, follow-up appointments were arranged, and home health services were confirmed before discharge.
The facility's own policy required developing individualized post-discharge plans and reviewing them with residents and families at least 24 hours before discharge. The policy specified that arrangements for follow-up care and the capacity of caregivers to perform required care must be evaluated.
The Rehabilitation Director expressed frustration with how the discharge was handled: "I was very upset how it went down. The facility was not ready to discharge Resident 2 when Resident 2's HIC called the facility on 7/9/2024."
In a separate case, the facility failed to provide adequate social services for another resident who needed placement in a Medicaid-certified long-term care facility. The Social Services Director could not provide documented evidence of referrals to appropriate facilities, despite telling inspectors she had made multiple attempts.
The Director of Nursing stated that "complete, accurate, and timely documentation of the referrals made to Medicaid-certified LTC facilities and any assistance provided by the facility to Resident 1 was important to show that the facility helped Resident 1 and/or R1R as much as possible to ensure a safe discharge from the facility."
The facility also failed to maintain accurate medical records, incorrectly documenting a patient's legal decision-maker on admission records, which could delay care decisions.
The stroke patient's family member never appealed the insurance decision because the facility told her it could take 30 days. She remains at home, dependent on a family member who lacks the physical ability and training to provide the level of assistance she requires.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bayshire San Dimas Post-acute from 2024-07-18 including all violations, facility responses, and corrective action plans.
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