Health inspection·March 27, 2025

Citation B – Ombudsman Notification 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. (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. It was determined based on interview and record review, the facility failed to ensure a copy of the written proposed discharge notice for Patient 1 was provided to the Office of the State Long Term (LTC) Ombudsman (advocate for patients to protect patient’s rights and ensure quality of care) the same time notice was provided to the patient or the patient’s representative. The notice of the proposed discharge was provided to the patient on January 29, 2025, and Patient 1 was discharged from the facility on January 31, 2025. This failure had the potential for the Ombudsman not to have the opportunity to advocate in protecting the patient’s rights from inappropriately discharged or transferred. A review of Patient 1's admission record indicated Patient 1 was admitted to the facility on October 13, 2024, with diagnoses which included esophageal cancer (a rare cancer that occurs when cells in the esophagus is a muscular tube that moves food and liquids from the throat to the stomach mutate and grow out of control). A review of Patient 1's “History and Physical,” dated October 14, 2024, indicated Patient 1 had the capacity to understand and make decisions. A review of the “Physician Order,” dated January 30, 2025, indicated Patient 1 was to be discharged to (Name of facility) on January 31, 2025. A review of the “Notice of Proposed Transfer/Discharge,” dated January 29, 2025, indicated Patient 1 had given verbal consent to the Proposed Transfer/Discharge plan. Further review of the proposed transfer or discharge notice indicated a copy was sent to the Ombudsman on February 3, 2025 (Five days after the proposed notice was provided to Patient 1). A review of the “Nurse Progress Note,” dated January 31, 2025, indicated Patient 1 had been discharged to (Name of Facility). On February 3, 2025, at 1:26 p.m., during a concurrent record review and interview with the Social Services Director (SSD), the SSD stated, Patient 1 had given verbal consent to the proposed discharge on January 29, 2025. The SSD stated she should have faxed the notice to the LTC Ombudsman on January 29, 2025, when Patient 1 received the discharge notice. The SSD stated the patient or the patient’s representative should sign the notice of the proposed discharge and for the facility to fax a copy of the notice to the LTC Ombudsman. A review of the policy titled, “Transfer and Discharge (including AMA),” dated December 19, 2022, indicated, “...Policy Explanation and Compliance Guidelines...Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the resident…the notice must be provided to the resident...and LTC ombudsman as soon as practicable before the transfer or discharge...” Based on interview and record review, the facility failed to ensure a copy of the written proposed discharge notice for Patient 1 was provided to the Office of the LTC Ombudsman, the same time notice was provided to the patient or the patient’s representative. The notice of the proposed discharge was provided to the patient on January 29, 2025, and Patient 1 was discharged from the facility on January 31, 2025. This failure had the potential for the Ombudsman not to have the opportunity to advocate in protecting the patient’s rights from inappropriately discharged or transferred. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.