Other·May 28, 2024

California Code, Health, and Safety Code - 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. CFR 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 (LTC) Ombudsman. On April 15, 2024, at 10:00 am, an unannounced visit was conducted at the facility to investigate an admission, transfer, discharge rights concern. It was determined that the facility failed to ensure a copy of the written notice of transfer or discharge was provided to the local Long-Term Care (LTC) Ombudsman when Patient 5 was discharged to home on March 29, 2024. This failure placed Patient 5 at an increased risk of being discharged without having an advocate to ensure a safe and effective transition of care, or without having a clear understanding of her appeal and discharge rights. A review of Patient 5's record was conducted. Patient 5 was admitted to the facility on February 19, 2024, with diagnoses which included heart failure, atrial fibrillation (rapid and irregular heart rhythm) and hyperlipidemia (high cholesterol level). Patient 5 was discharged home on March 29, 2024. The Notice of Proposed Discharge (NOPD) was initiated but was incomplete. There was no documented evidence that the LTC Ombudsman was notified of Patient 5's discharge to home. On April 15, 2024, at 12:22 p.m., an interview with the Social Service Designee (SSD) and a review of Patient 5's record were conducted. The SSD stated Patient 5 was discharged to home on March 29, 2024. The SSD stated the facility initiated Patient 5's discharge. The SSD stated the NOPD was incomplete, and she was not sure what was given to Patient 5. The SSD further stated the NOPD should have been completed. In addition, the SSD stated the LTC Ombudsman was not notified of Patient 5's discharge. The SSD further stated, she sent the NOPDs to the LTC Ombudsman weekly, on Fridays, via fax (facsimile, electronic communication). On April 15, 2024, at 2:12 p.m., a concurrent interview with the Director of Nursing and record review of Patients 5's record were conducted The DON stated the facility initiated Patient 5's discharge. The DON stated the SSD should have completed the NOPD. The DON further stated, it was important to send the NOPDs to the LTC Ombudsman so that the LTC Ombudsman will be able to follow up with the patients. On April 15, 2024, at 3:46 p.m., a follow up interview was conducted with the SSD. The SSD stated she did not send any NOPDs to the LTC Ombudsman on April 12, 2024, because she had sent some on April 9, 2024. The SSD stated she waits until there were sufficient discharges before sending the NOPDs to the LTC Ombudsman. The SSD stated NOPDs should be provided to the patient or responsible party as soon as a discharge date has been established. A review of the facility document titled, "Notice of Proposed Discharge Log" dated April 9, 2024, indicated there was a total of 18 residents discharged from the facility between March 19, 2024, and April 9, 2024. Patient 5 was not included on the facility document. The facility document indicated that the NOPDs were faxed to the LTC Ombudsman on April 9, 2024. A review of the facility's policy and procedure titled "Transfer or Discharge Notice, "dated March 2021 was reviewed. The policy indicated "...the resident and representative are notified in writing of the following information: a. the specific reason for the transfer or discharge; b. the effective date of the transfer or discharge; c. the location to which the resident is being transferred or discharged...a copy of the notice is sent to the Office of the State-Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative..." The facility failed to ensure a copy of the written notice of proposed discharge or transfer was provided to the local LTC Ombudsman when Patient 5 was discharged to home on March 29, 2024. This failure placed Patient 5 at an increased risk of being transferred without having an advocate to ensure a safe and effective transition of care, or without having a clear understanding of her appeal and transfer rights. This violation had a direct or immediate relationship to the health, safety, or security of the patient.