Health inspection·April 25, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Long Term Care Ombudsman office (LTC-Ombudsman, a resident advocacy agency) of transfer to the hospital for one of three sampled residents (Resident 1) when the facility failed to send a copy of Resident 1's transfer and discharge notification to the local LTC-Ombudsman office. This failure resulted in the LTC-Ombudsman not aware of Resident 1's discharge circumstances should appeals be filed by the resident or his representative. Findings: During a review of Resident 1's admission Record (AR, documents containing resident demographic information and medical diagnosis), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy (a disorder caused by a buildup of toxins in the brain that can happen with advanced liver disease), Pneumonia (lung infection caused by bacteria), Type 2 Diabetes Mellitus (a disorder in which blood sugar or glucose levels are abnormally high), Hypertension (high blood pressure), Congestive Heart Failure (the heart cannot pump blood or fill adequately), and End Stage Renal Diseases (inability of the kidney to function resulting to build up of toxins in the body and affecting major body organs). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 3/7/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated Resident 1 had no cognitive impairment (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent interview and record review on 4/25/24, at 11:30 a.m., with the Director of Nursing (DON), Resident 1's Nursing Progress Note (NPN), dated 3/31/24 was reviewed. The NPN indicated, . Situation: edema to abdomen and scrotum. Resident requesting to be sent to [hospital] . Orders to send to [acute hospital] for eval and treatment. Resident owns Responsible Party . DON stated Resident 1 did not return to the facility after he was transferred to acute hospital on 3/31/24. During an interview on 4/25/24, at 11:40 a.m., with the Social Services Director (SSD), the SSD stated he did not notify the State LTC Ombudsman office when Resident 1 was transferred to acute hospital on 3/31/24. SSD stated he was not aware of the requirements to notify the local LTC-Ombudsman office when a resident was transferred and admitted to the hospital. The SSD stated, I send a notice of discharge to the Ombudsman office via fax for residents who went home after discharge from the Page 1 of 2 055410 055410 04/25/2024 Brighton Post Acute 361 E. Grangeville Blvd Hanford, CA 93230

F 0623 facility, but not for residents transferred to the hospital. Level of Harm - Minimal harm or potential for actual harm During a phone interview on 4/25/24, at 1:00 p.m., with LTC-Ombudsman, LTC-Ombudsman stated she did not receive a copy of Resident 1's transfer and discharge notification from the facility. LTC-Ombudsman stated without the transfer and discharge notification, she could not act promptly should appeals be filed by Resident 1 or his legal representative. LTC-Ombudsman stated she was not getting any transfer and discharge notification from the facility for any resident who went to the hospital. Residents Affected - Few During a phone interview on 4/26/24, at 2:10 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility failed to notify the LTC Ombudsman office of Resident 1's transfer to the hospital on 3/31/24. The ADON stated without the knowledge of Resident 1's discharge circumstances, the LTCOmbudsman could not act promptly should appeals be filed by the resident or his representative. During a review of Professional reference titled, CMS Issues Clarification of Notice Requirements to Long-Term Care Ombudsman when Resident is transferred or discharged from Long-Term Care Facility dated 7/24/17, (found at https://www.hallrender.com/2017/07/24/cms-issues-clarification-of notice requirements) indicated . On May 12, 2017, the Survey and Certification Group at Centers for Medicare and Medicaid Services (CMS) issued a memorandum, Implementation Issues, Long-Term Care Regulatory Changes . Clarification of Notice before Transfer or Discharge Requirements clarifying the requirements of the Final Rule regarding the timing for providing notice to the State Long-Term Care Ombudsman in the event a resident is transferred or discharged from the long-term care facility. Facilities must immediately review and revise their discharge and transfer notice practices, policies and procedures . 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 . Copies of notices for emergency transfers must also still be sent to the Ombudsman . 055410 Page 2 of 2