Health inspection·December 18, 2023

REGULATION VIOLATION(S): HSC 1439.6 (a), (b) and (c) (a) Except as provided in subdivision (b), if a resident is notified in writing of a facility-initiated transfer or discharge from a long-term health care facility, the facility shall also send a copy of the notice to the local long-term care ombudsman at the same time notice is provided to the resident or the resident's representative. (b) If a resident is subject to a facility-initiated transfer to a general acute care hospital on an emergency basis, the facility shall provide a copy of the notice to the ombudsman as soon as practicable. (c) The copy of the notice shall be sent by fax machine or email, as may be directed by the local long-term care ombudsman, unless the facility does not have fax or email capability, in which case the copy of the notice shall be sent by first-class mail, postage prepaid. A facility's failure to timely send a copy of the notice shall constitute a class B violation, as defined in subdivision (e) of Section 1424. The facility failed to send a copy of "Notice of Discharge" to the representative of the Office of the State Long-Term Care (LTC) Ombudsman [a public advocate (official) is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights] for Resident 4 prior to his discharge to home. This failure had the potential for Resident 4 being inappropriately discharged and not being provided an advocate who could inform Resident 4 of their rights and options if Resident 4 was not ready to be discharged to home. A review of Resident 4's "Post-Discharge Plan of Care - V2," effective dated 3/4/21, and "Progress Notes," dated 3/5/21, indicated Resident 4 was discharged to a homeless shelter on 3/5/21 at 10:30 a.m. Resident 4's "Notice of Proposed Transfer and Discharge," discharge effective date 3/5/21, indicated Resident 4 was to be discharged to a homeless shelter on 3/5/21, but the notification was not faxed to the Ombudsman's office until 3/5/21 at 6:43 p.m. per the faxed transmission verification. During an interview on 3/23/21 at 12:50 p.m., Administrative Staff A and Administrative Staff B stated they both informed the ombudsman about a resident being discharged or transferred via way of Medical Records faxing the "Discharge/Transfer" form to the Ombudsman's office after the resident was discharged or transferred. Administrative Staff A and Administrative Staff B were not aware why the ombudsman needed to be informed prior to the resident's discharge. During an interview on 3/23/21 at 3:10 p.m., Administrative Staff C stated she thought the "Notice of Transfer and Discharge," was sent to the Ombudsman's office to inform the office the resident was discharged or transferred. When Administrative Staff C was asked what the ombudsman was for, Administrative Staff C stated an ombudsman advocated for the residents. When asked how the ombudsman would be able to advocate for the resident after the resident was discharged, Administrative Staff C stated the ombudsman could not advocate for the resident once the resident was discharged. Administrative Staff C stated she now understood the reason the Ombudsman's office needed to be notified prior to a resident's discharge. During an interview on 3/23/21 at 4:15 p.m., the DON (Director of Nursing) stated it was the responsibility of Social Services to notify the Ombudsman office when a resident was discharged or transferred to another facility. There was no Social Services and Case Manager for a while, so Administrative Staff C was faxing the "Notice of Transfer and Discharge" to the Ombudsman's office after the resident was discharged. The DON stated she did not realize the Ombudsman's office needed to be notified prior to the resident's discharge. The DON did not think about residents needing the ombudsman to act as an advocate because the resident had a conflict with their discharge date. During an interview on 4/13/21 at 11:05 a.m., Administrative Staff B stated he was not notifying the Ombudsman's office prior to the resident's discharge. Administrative Staff B stated he was notifying the Ombudsman's office after the resident was discharged. Administrative Staff B stated he realized the Ombudsman was an advocate for the resident. Notifying the ombudsman after the resident was discharged was not helping the resident if they had questions/issues regarding their discharge date. The facility policy/procedure titled, "Transfer or Discharge Notice," revised 12/2016, indicated: "3. The resident and/or representative (sponsor) will be notified in writing of the following information: f. The name, address, e-mail and telephone number of the Office of the State Long-Term Care Ombudsman... 4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman." A document titled "All Facility Letter (17-27) Summary," dated 12/27/17, based on Health and Safety Code (HSC) section 1439.6, which indicated Long Term Care (LTC) facilities were to notify the local LTC Ombudsman at the same time notice is provided to the resident or resident's representatives when a facility-initiated transfer or discharge occurred. The facility must send a notice to the local Ombudsman for any transfer or discharge that is initiated by the facility, whether or not the resident agrees with the facility's decision. Therefore, this failure had the potential for Resident 4 being inappropriately discharged on 3/5/21, and not being provided an advocate who could inform Resident 4 of his rights and options before being discharge to home. The violation of the regulation had a direct relationship to the health, safety, or security of residents.