Health inspection·March 21, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # CA00879338 Survey Event ID: I60H11 Representing the Department, HFEN #43071 State Citation B was written. § 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. (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. §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) 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 send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. On 1/23/24 at 10:13 a.m., an unannounced visit was conducted at the facility to conduct the investigation of a complaint survey. The department determined the facility failed to provide notice of a facility-initiated discharge (a resident is given a 30 day notice to find another place to live) to the appropriate parties for Resident 1 when, Resident 1's representative (RR, a designated person to make decisions for another person) was provided a notice of discharge on 11/20/23 and the notice was not sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman (a resident rights advocator) at the same time. This failure had the potential for the State LTC Ombudsman not being aware of Resident 1's facility-initiated transfer/discharge and potentially prevented the opportunity for the State LTC Ombudsman to advocate for Resident 1's right. Review of Resident 1's Social Services Note dated 11/20/23, indicated, "The resident's [Resident 1] son met with the Administrator, DON [Director of Nursing] & SSD [Social Services Director]. The son was issued a Notice of Transfer/Discharge. It was explained to the son that he should be prepared to transfer/discharge at the end of 30 days from the date of the Notice of Transfer/Discharge..." Review of Resident 1's "NOTICE OF TRANSFER / DISCHARGE," dated 11/20/23, indicated, "...Notification Date: 11/20/2023...Effective Date: 12/20/2023...This notice is to inform you that transfer/discharge is necessary for the following reason... [box was marked in front of the following reason] The safety of individuals in the facility is endangered due to your clinical or behavioral status..." During an interview on 2/22/24, at 1:57 p.m., the Administrator (ADM) stated Resident 1's transfer/discharge notice was not sent to the State LTC Ombudsman Office. The ADM stated the notice of transfer/discharge should be sent to the State LTC Ombudsman office for a facility-initiated discharge at the same time the notice was issued to the resident. During an interview on 2/27/24, at 12:28 p.m., the SSD stated Resident 1's notice of transfer/discharge was given to Resident 1's representative on 11/20/23. The SSD stated the facility initiated Resident 1's discharge because of Resident 1's behavior of hitting other residents. The SSD stated a copy of Resident 1's notice of transfer/discharge was not sent to the Ombudsman's office. The SSD further stated she was under the impression that they needed to send the notice of transfer/discharge to the Ombudsman office after the resident left the facility. The SSD stated after they [facility staff] reviewed the documents in depth, she was now aware that the minute the notice of transfer/discharge was issued to the resident, the notice also needed to be sent to the Ombudsman's office. The SSD stated the notice of transfer/discharge needed to be sent to the Ombudsman's office at the same time it was issued to the resident/RR, so the Ombudsman was aware of the resident's discharge/transfer notice being issued in case the resident wanted to appeal the decision. The SSD stated the Ombudsman was an advocate for residents and their rights. Review of a facility provided document titled "STATE OF CALIFORNIA OFFICE OF THE STATE LONG-TERM CARE OMBUDSMAN SENDING REQUIRED TRANSFER/DISCHARGE NOTICES TO YOUR LOCAL LONG-TERM CARE OMBUDSMAN PROGRAM," revised 5/2022, indicated "...Facilities are required to send copies of all notices related to facility-initiated transfers and discharges...Facilities must give residents and their representatives a notice of discharge or transfer at least 30 days in advance...The facility must send copies of these notices to the LTCOP [Ombudsman] at the same time..." Therefore, the Department determined the facility failed to provide notice of a facility-initiated discharge to the appropriate parties for Resident 1 when, Resident 1's representative was provided a notice of discharge on 11/20/23 and the notice was not sent to a representative of the Office of the State Long-Term Care Ombudsman at the same time. This failure had the potential for the State LTC Ombudsman not being aware of Resident 1's facility-initiated transfer/discharge and potentially prevented the opportunity for the State LTC Ombudsman to advocate for resident 1's right. This violation had a direct or immediate relationship to the health, safety, and security of residents.