Other·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 3 prior to her discharge to home. This failure had the potential for Resident 3 being inappropriately discharged and not being provided an advocate who could inform Resident 3 of their rights and options if Resident 3 was not ready to be discharged to home. A review of Resident 3's "Skilled Nursing Facility Discharge Orders," dated 11/27/20, and "Progress Notes," dated 11/30/20, indicated Resident 3 was discharged to home on 11/30/20 at 2:10 p.m. Resident 3's "Notice of Transfer/Discharge," dated 11/30/20, indicating Resident 3 was going to be discharged to home on 11/30/20, was faxed to the Ombudsman's office at the same time the resident was discharge to home, which was on 11/30//20 at 2:10 p.m. per the faxed transmission verification. During an interview on 12/17/20 at 2:10 p.m., Administrative Staff A stated she faxed the "Notice of Transfer/Discharge" to the Ombudsman's office the day of the resident's discharge or the day after the resident was discharged. If the resident was discharged over the weekend, the notice would be faxed to the Ombudsman's office on Monday. When Administrative Staff A was asked if the resident was unhappy with their discharge date, how was the resident able to use the Ombudsman as their advocate if the Ombudsman was not aware of the resident's discharge until after the resident was discharged. Administrative Staff A stated the resident would not be able to use the Ombudsman after the resident was discharged. Administrative Staff A stated she was now aware she was wrong to send the "Notice of Transfer/Discharge" to the Ombudsman's office after the resident was discharge. The facility police/procedure titled, "Transfer or Discharge Notice," revised 12/16, indicated #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 12/26/17, 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 the resident agrees with the facility's decision. Therefore, this failure had the potential for Resident 3 being inappropriately discharged on 11/30/20, and not being provided an advocate who could inform Resident 3 of her 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.