Other·February 18, 2022

§ 483.15 (c)(5)(vii) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: For Nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility must ensure that a resident with mental illness would be provided with a Notice of Transfer/Discharge that contain the mailing and email address and telephone number of Disability Rights California (DRC), the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to follow its policy and procedure on Transfer and Discharge, when it planned for a facility-initiated involuntary discharge (A transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences) on a resident, Resident 1, and the Notice of Transfer /Discharge provided to him did not contain the mailing and email address and telephone number of Disability Rights California (DRC), the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. This failure had the potential to result in a delay of behavioral intervention should Resident 1's mental illness lead to a mental health crisis (A mental health crisis is any situation in which a person's behavior puts them at risk of hurting themselves or others and/or prevents them from being able to care for themselves or function effectively in the community), and he did not have any information on who and which agency to reach out to. On 8/3/2021, the California Department of Public Health (CDPH) Licensing and Certification (L&C) program, received an anonymous complaint alleging that the facility has not complied with the legal requirements to involuntarily discharge Resident 1. The complaint was investigated on 8/6/2021, and during this facility visit, Resident 1 refused to be interviewed. During a review of Resident 1's, "Admission Record," dated 2/24/2021, the Admission Record indicated Resident 1 was admitted to the facility due to an infection on his right lower limb. The Admission Record indicated Resident 1 had a diagnosis of Schizophrenia (Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves). During a review of a facility document titled, "Notice of Transfer/Discharge," dated and signed by the facility Administrator on 3/18/2021, the Notice of Transfer/Discharge did not contain the mailing and email address and telephone number of Disability Rights California, the agency designated under federal law to protect and advocate for the rights of Californians with disabilities. During an interview on 9/29/2021, at 9:50 a.m., with Administrative Staff A, Administrative Staff A stated she sent the Notice of Transfer/Discharge to the county Ombudsman (a person who investigates, reports on, and helps settle complaints) on 3/18/2021. Administrative Staff A stated she was not aware at that time that the mailing and email address and telephone number of Disability Rights California should be included in the notice. During a review of a facility policy and procedure (P&P) titled, "Transfer or Discharge Notice Policy," dated 1/1/2016, the P&P indicated, "The resident and/or representative (sponsor) will be provided with the following information: ... The name, address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmentally disabled individuals (as applies)." Therefore, the facility failed to follow its policy and procedure on Transfer and Discharge, when it planned for a facility-initiated involuntary discharge (A transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences) on a resident, Resident 1, and the Notice of Transfer /Discharge provided to him did not contain the mailing and email address and telephone number of Disability Rights California (DRC), the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. This failure had the potential to result in a delay of behavioral intervention should Resident 1's mental illness lead to a mental health crisis (A mental health crisis is any situation in which a person's behavior puts them at risk of hurting themselves or others and/or prevents them from being able to care for themselves or function effectively in the community), and he did not have any information on who and which agency to reach out to. The violation of the regulation had the potential to result in physical or psychological harm to Resident 1.