Health inspection·October 18, 2024

“B” Citation Oak Glen Post Acute Complaint: CA00918531 Health and Safety Code 1439.6 (a) Except as provided in subdivision (b), if a patient 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 patient or the patient’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. 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 when Patient 1 was transferred to the general acute care hospital (GACH) on July 15, 2024. This failure has the potential for the Ombudsman not to be able to advocate in protecting the rights from inappropriate transfer and discharge for Patient 1. On September 4, 2024, Patient 1's record was reviewed. Patient 1 was admitted to the facility on June 2, 2024, with diagnoses which included muscle wasting (loss of muscle strength) and atrophy (thinning of muscles). A review of Patient 1’s "Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form, "dated July 15, 2024, indicated, "...Sent to (name of hospital)...Reinsertion of dislodged suprapubic catheter (medical device that drains urine from bladder)..." A review of Patient 1's progress notes did not indicate documented evidence the facility mailed or faxed Patient 1's transfer or discharge notice to the LTC Ombudsman. On September 4, 2024, at 2:36 p.m., during a concurrent interview and review of Patient 1’s medical records with the Director of Nursing (DON), she stated the transfer or discharge notice would be given to the patient upon transfer of discharge from the facility and the Social Service Director (SSD) would send the discharge notice to the LTC Ombudsman within 30 days of transfer. The DON stated Patient 1 was transferred to the hospital on July 15, 2024, and was discharged from the facility on July 23, 2024. The DON stated the discharge notice was not sent to the LTC Ombudsman. The DON further stated the SSD should have sent Patient 1's discharge notice to the Ombudsman. On September 4, 2024, at 2:56 p.m., during a concurrent interview and review of Patient 1’s medical record with the SSD, she stated the facility would send the discharge or transfer notice to the LTC Ombudsman within 30 days of the patient's transfer or discharge from the facility. The SSD verified Patient 1 was transferred to the hospital on July 15, 2024, and was discharged from the facility on July 23, 2024. The SSD stated she did not send Patient 1’s discharge notice to the LTC Ombudsman. The SSD further stated, "I did not know I have to send it when a resident is transferred." A review of the facility policy and procedure titled, "Transfer or Discharge Notice," dated March 2021, indicated, "...Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge...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...This policy applies to facility-initiated transfer..." 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 LTC Ombudsman, when Patient 1 was transferred to the GACH on July 15, 2024. This failure has the potential for the Ombudsman not to be able to advocate in protecting the rights from inappropriate transfer and discharge for Patient 1. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.