Other·April 8, 2021

HSC 1439.6 (a), (b) and (c) (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," 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 mal-administration or a violation of rights] for Resident 57, prior to her discharge to home. This failure had the potential for Resident 57 being inappropriately discharged by not being provided an advocate who could inform her of her rights and options, if she felt she was not ready to be discharged to home. During Resident 57's clinical record review, dated 5/16/18, the Discharge Notes did not indicate the facility notified the Ombudsman's office prior to Resident 57's discharge. Resident 57 was admitted on 5/02/18, from an acute care facility for continuation of physical and occupational therapy. Resident 57's condition improved, and she was discharged to the community (Home) to continue PT (Physical Therapy) and OT (Occupational Therapy) as an out-patient. During an interview on 8/16/18 at 10:04 a.m., Administrative Staff B stated she was not aware the Ombudsman's office needed to be notified of all facility-initiated transfers or discharges, at the same time the resident or the resident's representative was notified of the discharge. Administrative Staff B stated she was in charge of notifying the Ombudsman's office, but she thought the Ombudsman's office was only to be notified if there was an unusual circumstance whereby the facility was discharging the resident. Administrative Staff B stated she had not been sending the, "Notice of Discharge," to the Ombudsman's office prior to a resident's discharge, which included Resident 57. During an interview 8/17/18 at 3:23 p.m., the DON (Director of Nurses) stated the facility had not been notifying the Ombudsman's office regarding a resident's discharge and was not familiar with the new regulation. The facility policy/procedure titled, "Transfer and Discharge," updated 3/2017, indicated, when the transfer or discharge is initiated by the facility, the resident receives written notice using the Resident Notice of Transfer or Discharge and the facility sends a copy of the notice to the State Long-Term Care Ombudsman. The facility failed to send a copy of Notification to the local Long-Term Care Ombudsman of the facility-initiated discharge of Resident 57, prior to her discharge to home. This failure had the potential for Resident 57 being inappropriately discharged by not being provided an advocate who could inform her of her rights and options if she was not ready to be discharged to home. The violation of the regulation had a direct relationship to the health, safety, or security of Resident 57.