Other·April 10, 2025

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 (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. 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 January 27, 2025. 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 February 24, 2025, a review of Patient 1's admission record indicated Patent 1 was admitted to the facility on January 21, 2025. A review of Patient 1's “History and Physical,” dated January 24, 2025, indicated Patient1 had fluctuating capacity to make medical decisions. A review of Patient 1’s “Physician Order,” dated January 27, 2025, indicated, “...Send to ER (emergency room) for eval (sic) (evaluation) and treatment...” A review of Patient 1’s “eINTERACT Transfer Form,” dated January 27, 2025, indicated, “...Sent to (name of hospital)...Reasons: Dislodgement and dislocation of R (sic) (right) shoulder prosthesis (a device designed to replace or make a part of the body work better)...” Further review of Patient 1’s medical records indicated, there was no documented evidence the facility mailed or faxed a copy of the transfer or discharge notice to the LTC Ombudsman after Patient 1 was transferred to the GACH on January 27, 2025. On February 24, 2025, at 3:39 p.m., during a concurrent interview and review of Patient 1's notice of transfer or discharge record with the Director of Nursing (DON), she stated when patients are transferred or discharged from the facility, the Social Service Director (SSD) is responsible for sending the transfer or discharge notice to the LTC Ombudsman the same day or the next business day. The DON stated Patient 1 was transferred to the hospital on January 27, 2025, and the discharge notice was not sent to the LTC Ombudsman. The DON further stated the SSD should have sent the notice to the Ombudsman. On February 24, 2025, at 3:39 p.m., during a concurrent interview and review of Patient 1's notice of transfer or discharge record with the SSD, he stated for patients who were transferred or discharged from the facility, the LTC Ombudsman is sent a letter to notify of the patient’s discharge the same day or the next business day. The SSD further stated Patient 1 was transferred to the hospital on January 27, 2025, and he did not send the discharge notice to the LTC Ombudsman. The SSD stated he should have sent the notice to ensure the LTC Ombudsman was made aware and able to advocate for Patient 1's care. A review of the facility policy and procedure titled, “Transfer or Discharge Notice,” dated 2021, indicated, “...Notice of transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care ombudsman when practicable...” 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 January 27, 2025. 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.