Other·March 14, 2024

California Health and Safety Code 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 Ombudsman. On February 1, 2024, at 9:15 a.m., an unannounced visit was conducted at the facility for a complaint investigation regarding a discharge 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 1 was transferred to the general acute care hospital (GACH) on December 11, 2023. This failure placed Patient 1 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. On February 1, 2024, Patient 1's facility medical record was reviewed. Patient 1 was admitted to the facility on September 21, 2022, with diagnoses which included schizoaffective disorder bipolar type (a long-term mental illness). Patient 1 was transferred to the GACH on December 11, 2023. The document titled, "Change of Condition," dated December 11, 2023, indicated Patient 1 was transferred to the GACH ER (emergency room) by ambulance for unresponsiveness. The physician and conservator were notified of the transfer. There was no documented evidence that a written notice of transfer or discharge was provided to the local LTC Ombudsman when Patient 1 was transferred to the GACH on December 11, 2023. On February 1, 2024, at 12:15 p.m., an interview was conducted with the facility Social Worker (SW). The SW stated she did not have the "Notice of Transfer/Discharge" because she does not notify the Office of the State LTC Ombudsman during an emergent hospital transfer. The SW further stated the Admission Coordinator handled the notifications regarding transfer and bed holds. On February 1, 2024, at 1:12 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Patient 1 was sent to the GACH on December 11, 2023. The DON stated the SW was responsible for providing written notifications of emergency transfers or discharges to the Office of the State LTC Ombudsman on the day of the transfer to the GACH. On February 1, 2024, at 3:00 p.m., a telephone interview was conducted with the LTC Ombudsman assigned to the facility. The LTC Ombudsman stated their office never received the "Notice of Transfer/Discharge" for Patient 1. On February 1, 2024, at 4:05 p.m., a telephone interview was conducted with the facility DON. The DON stated that the "Notice of Transfer/Discharge" was not sent to the Office of the State LTC Ombudsman. She stated Social Services was to fax the notification of Transfer or Discharge to the Office of the State LTC Ombudsman when patients transferred or discharged from the facility. A review of the facility policy and procedure titled, "TRANSFER OR DISCHARGE NOTICE," dated March 2021, was reviewed. The policy indicated, "...Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: ... An immediate transfer or discharge is required by the resident's urgent medical needs... A copy of the notice will be 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 transfer was provided to the local LTC Ombudsman when Patient 1 was transferred to the GACH on December 11, 2023. This failure placed Patient 1 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.