Health inspection·April 9, 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. (d) For the purposes of this section, a "facility-initiated transfer or discharge" is a transfer or discharge that is initiated by the facility and not by the resident, whether or not the resident agrees to the facility's decision. (Added by Stats. 2017, Ch. 274, Sec. 1. (AB 940) Effective January 1, 2018.) 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, who were discharged to home. This failure had the potential for Resident 3 being inappropriately discharged and not being provided an advocate who could inform them of their rights and options if they were not ready to be discharged home. During an interview on 6/7/21 at 9:15 a.m., with Administrator, Administrator stated the person who had been responsible for sending notices to the Ombudsman office regarding resident discharges to home, other facilities, or higher levels of care had vacated the position. Administrator stated he had been processing discharges with the assistance of the Activity Director but was not sure which staff member had been notifying the Ombudsman. During an interview on 6/7/21 at 12:57 p.m., with Activity Director (AD), she stated she was assisting in some resident discharges, as in those residents returning home or transferring to another facility. AD stated she remembered notifying the Ombudsman office of some resident discharges but could not remember specific examples. AD stated she was not handling all of the discharges as the duties were being split between the Administrator and herself. During an interview on 6/7/21 at 1:55 p.m., with Administrator, he stated the Ombudsman office had been notified of discharges once a month, but he was not sure who had been completing the notifications. Administrator stated he was not sure the appropriate time frame of when the notifications were supposed to occur and would have to check with the Ombudsman office to confirm which notifications had been submitted. During a review of an electronic correspondence dated 6/8/21 at 6:04 p.m., Administrator documented the residents who had left the facility from March 1, 2021, through to June 7, 2021. The electronic correspondence indicted the facility did not send a notice to the Ombudsman office for Resident 3. A review of Resident 3's "Progress Notes," dated 3/6/21 at 1:00 pm, indicated Resident 3 was discharged to home with follow up doctor appointments and home health referral. During a review of the facility's policy and procedure (P&P) titled, "Transfer and Discharge Notice," effective 10/2017, the P&P indicated, "1. A resident ... will be given thirty (30)-day advance notice of an impending transfer or discharge from our facility," ... and "[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, the facility failed to send a copy of Notification to the local Long-Term Care Ombudsman of the facility-initiated discharge of Resident 3 prior to their discharge to home on 3/6/21. This failure prevented the Ombudsman from advocating for Resident 3. The violation of the regulation had a direct relationship to the health, safety, or security of residents. During a review of the facility's policy and procedure (P&P) titled, "Transfer and Discharge Notice," effective 10/2017, the P&P indicated, "1. A resident ... will be given thirty (30)-day advance notice of an impending transfer or discharge from our facility," ... and "[a] copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman."