Other·September 6, 2022

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 November 18, 2020, at 10:25 a.m., an unannounced visit was conducted at the facility for a complaint investigation for quality-of-care concerns. 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 Ombudsman when Patient 2 was transferred to the general acute care hospital (GACH) on August 8, 2020. This failure placed Patient 2 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 his appeal and transfer rights. On November 18, 2020, Patient 2's facility medical record was reviewed. Patient 2 was admitted to the facility on September 25, 2019, with diagnoses which included Parkinson's disease (a disorder that affects movement), hypertension (high blood pressure), and pressure ulcer (bed sore). Patient 2 was transferred to the GACH on August 8, 2020. Patient 2's facility "Licensed Nurse’s Progress Note," dated August 8, 2020, at 9 p.m., indicated, "…Resident sent to (name of GACH) ER (emergency room) for further eval (evaluation)…" Patient 2's untitled facility document dated August 8, 2020, indicated, "…Send resident to (name of GACH) ER for further eval…" Further review of Patient 2's facility medical record failed to identify documented evidence that a written notice of transfer or discharge was provided to the local long-term care Ombudsman when Patient 2 was transferred to the GACH on August 8, 2020. On December 21, 2020, at 2:15 p.m., a telephone interview was conducted with the facility Director of Nursing (DON). The DON stated that the "Notice of Transfer/Discharge" was not sent to the Office of the State Long-Term Care Ombudsman. He stated social services were not aware that when patients were transferred out of the facility to the GACH, home or other facilities the Office of the State Long-Term Care Ombudsman was to be notified. He further stated he was unaware of the facility’s procedure for notification to the Office of the State Long-Term Care Ombudsman when patients transferred or discharged from the facility. The facility failed to ensure a copy of the written notice of transfer was provided to the local long-term care Ombudsman when Patient 2 was transferred to the GACH on August 8, 2020. This failure placed Patient 2 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.