Health inspection·July 1, 2021

§1439.6(a)(b)(c) The facility failed to send a copy of, " Notice of Discharge/Transfer," 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] prior to an Unsampled Resident's (Resident 44) discharge to home. This failure had the potential for Resident 44 being inappropriately discharged and/or not being provided an advocate who could inform her of her rights, and options, if she was not ready to be discharged home or transferred to an acute care facility. During a concurrent interview and record review on 12/13/19 at 12:14 p.m., Resident 44's, "Facility Discharge Summary," dated 11/27/19, "Interdisciplinary Discharge Summary," dated 11/29/19, "Notice of Transfer or Discharge," dated 11/29/19, and "Nurse's Progress Note," dated 11/29/19, all indicated she was discharged to home on 11/29/19, but the, "Discharge List/Conversion List," which Administrative Staff E sent to the Ombudsman's office, informing the Ombudsman of Resident 44's discharge, was not faxed until 12/9/19, per the "Transmission Verification Report," located on the faxed cover sheet. Administrative Staff E stated she was not aware of needing to send the, "Discharge Notice," to the Ombudsman's office prior to a resident being discharged. Administrative Staff E stated she was sending a, "Discharge List," to the Ombudsman's office once a month. Administrative Staff E stated she understood why the Ombudsman's office should have been notified prior to the resident's discharge; so, she/he could act as the resident's advocate in case they were upset about their facility-driven discharge. The facility policy/procedure titled, "Transfer or Discharge Notice," revised 2016, indicated, "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 12/26/17, based on Health and Safety Code (HSC) Section 1439.6, indicated Long Term Care (LTC) facilities were to notify the local LTC Ombudsman at the same time notice was provided to the resident or the 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 was initiated by the facility, whether or not the resident agreed 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 44, prior to her discharge to home. This failure had the potential for Resident 44 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 above violation had a direct or immediate relationship to the health, safety, or security of Resident 44.