Other·April 25, 2024

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. Health and Safety Code 1439.6 (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. Code of Federal Regulations, Title 42, §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 15, 2024, at 9:45 a.m., an unannounced visit was made to the facility to investigate a transfer and discharge issue. It was determined that the facility failed to ensure the notice of transfer or discharge was sent to the Office of the Long-Term Care (LTC) Ombudsman at the same time the notice was provided to Patient 1. This failure has the potential for the Ombudsman not to be able to advocate for the patient in protecting patient's rights from inappropriate transfer and discharge. A review of Patient 1's admission face sheet dated February 15, 2024, indicated the patient was admitted to the facility on May 28, 2023, with diagnoses which included neuropathy (Diseased or nerve damage causing numbness or weakness). The face sheet further indicated the patient was discharged on December 19, 2023. A review of Patient 1’s “Notice of Transfer/Discharge,” dated December 19, 2023, indicated, “…Notification date (Date resident was notified they would be discharging from the facility) November 15, 2023, … Effective date: December 19, 2023, …” On February 15, 2024, at 1:09 p.m., during interview, the facility Discharge Planner stated at the time of a patient's discharge, the family or the patient would receive a copy of the notice (Notice of Transfer/Discharge) and the notice would be faxed to the Ombudsman. The facility discharge planner verified the facility would fax the copy of the notice to the Ombudsman after the patient signs the notice, on the day of the discharge. On February 15, 2024, at 2:18 p.m., during interview, the Director of Nursing (DON) stated the process to maintain evidence that the discharge notice was sent to the Ombudsman office would include for the desk/or discharge nurse to fax a copy of the notice to the Ombudsman's office, placing a copy of the fax confirmation in the Social Services (SS) basket, and for the SS to keep a copy of the fax confirmation for their records. On February 15, 2024, at 2:56 p.m., during interview, the Social Services Director (SSD) stated she used to keep a binder of faxed transmission and discharge documents sent to the Ombudsman. The SSD verified the facility has not been keeping evidence that the Ombudsman was notified of the patient's transfer and discharge. On February 15, 2024, at 3:48 p.m., during interview, the facility discharge planner verified she did not have a binder containing faxed copies of patient's notice of transfer and discharge to the Ombudsman office. The facility discharge planner stated she did not realize she was to maintain evidence that a copy of the Notice of Transfer/Discharge was sent to the Ombudsman office after a patient was discharged from the facility. A review of the facility Policy & Procedure, titled, “Transfer or Discharge Notice,” revised March 2021, indicated, “…Policy interpretation and Implementation … 3. Except as specified below, the resident and his or her representative are given a thirty (30)-day written notice of an impending transfer or discharge from this facility. 4. Under the following circumstances, the notice given as soon as it is practicable but before the transfer or discharge: e. The resident has not resided in the facility for thirty (30) days … 6. 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…” Based on interview and record review, it was determined that the facility failed to ensure the notice of transfer or discharge was sent to the Office of the Long-Term Care (LTC) Ombudsman at the same time the notice was provided to Patient 1. This failure has the potential for the Ombudsman not to be able to advocate for the patient in protecting patient's rights from inappropriate transfer and discharge. This violation had a direct or immediate relationship to the health, safety, security of the patients.