Health inspection·May 5, 2025

REGULATION VIOLATION(S) §HSC 1439.6 (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" form to the representative of the Office of the State Long-Term Care (LTC) Ombudsman [a public advocate (official) is an official who is in charge with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights] for Resident 1 prior to his discharge to home. This failure had the potential for Resident 1 being inappropriately discharged and not being provided an advocate who could inform Resident 1 of his rights and options if Resident 1 was not ready to be discharged to home. A review the facility document titled, "Admission/Discharge To/From Report," dated 11/1/22 to 2/8/23, indicated Resident 1 was discharged to home on 11/11/22 with no home health services. Resident 1's "Notice of Proposed Transfer and Discharge," notification date 11/9/22, indicated Resident 1's discharge effective date to home was 11/11/22. A review of the facility's "Fax Cover Sheet," indicated the Social Services sent the Ombudsman's office Resident 1's "Notice of Proposed Transfer and Discharge" on 11/11/22, the day Resident 1 was discharged home. There was no fax verification notice showing a date and time to verify when or if the notice was sent to the Ombudsman's office. During an interview on 2/8/23 at 11:35 a.m., the surveyor went over AFL (All Facility Letter) 17-27: Health & Safety Code for reporting to Ombudsman's office resident's discharge or transfer. The Administrator was not aware of the AFL or having to report a transfer to the Ombudsman's office. The Administrator stated Social Services took care of reporting discharges/transfers to the Ombudsman's office. During an interview on 2/8/23 at 12:40 p.m., the Social Services stated once the facility was done with a resident's discharge and the resident had left the facility, the Ombudsman's office was notified about the resident's discharge. The Social Services said, "He was just thrown into the water and hoped to swim." When the Social Services was asked why the Ombudsman came to the facility, the Social Services said, "The Ombudsman was a patient's rights advocacy." The Social Services stated he was not trained to let the Ombudsman know about the resident's discharge ahead of time. The Social Services stated sometimes the Ombudsman's office was not notified about a resident's discharge. 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 or not the resident agrees with the facility's decision. Failure to timely send a copy of the notice to the local LTC Ombudsman will constitute a class B violation, which may result in a monetary penalty between $100-$2000. The facility provided the document titled, "S & C (Survey and Certification Group): 17-27-NH, dated 5/12/17, indicated: "... Notice of Transfer or Discharge: The regulation at 42 CFR 483.15(c)(3)(i) requires, in part, that before a facility transfers or discharges a resident, the facility must "notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand...." The facility must also "...send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman... A. Facility-Initiated Transfers and Discharges: In situations where the facility has decided to discharge the resident while the resident is still hospitalized, the facility must send a notice of discharge to the resident and resident representative, and must also send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. Notice to the Office of the State LTC Ombudsman must occur at the same time the notice of discharge is provided to the resident and resident representative, even though, at the time of initial emergency transfer, sending a copy of the transfer notice to the ombudsman only needed to occur as soon as practicable as described below. For any other types of facility-initiated discharges, the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the ombudsman must be sent at the same time notice is provided to the resident and resident representative. Emergency Transfers: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable, according to 42 CFR 483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis." Therefore, this failure had the potential for Resident 1 being inappropriately discharged on 11/11/22, and not being provided an advocate who could inform him 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.