Other·March 28, 2024

B Citation- Failure to report to Ombudsman Manorcare Palm Desert Complaint Number: CA00877632 HFEN: Christopher Gary 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 January 4, 2024, at 11:00 a.m., an unannounced visit at the facility was conducted to investigate a complaint. Based on interview and record review, it was determined that the facility failed to ensure a copy of the written notice of transfer or discharge was provided to the long-term care Ombudsman for 30 of 50 patients, who were transferred and discharged from the facility between December 1, 2023, and January 2, 2024; in accordance with the facility policy and procedure. This failure had the potential to result in the discharged patients experiencing an inappropriate transfer or discharge and to not have the opportunity to speak with the Ombudsman to advocate in protecting the patient's rights from being inappropriately transferred or discharged. A review of Patient 1's admission record indicated the patient was admitted to the facility on November 30, 2023, with diagnoses which included femur (thigh bone) fracture, depression (mood disorder), and diabetes mellitus (inability to regulate blood sugar). A review of 1's Notice of Medicare Non-Coverage (NOMNC), undated, indicated the patient's skilled services would no longer be covered on January 1, 2024. The notice was not signed by the patient. A review of Patient 1's Discharge Planning/Discharge note dated December 28, 2023, at 3:28 pm by Case Manager (CM) indicated, "MD (Medical Doctor) in to see pt (patient) today for discharge planning. Case manager met with pt and parents for DC (discharge) planning and coordination of care at discharge. pt stable, pain managed with pain medications. pt continues NWB (non-weight bearing) to LLE (Left lower extremity) as per Ortho (Orthopedic physician) for an additional 4 weeks. Notice of Non-Coverage for Skilled services issued today. LCD (Last coverage day) 1/1/24, DC home on 1/2/24. HHPT (Home health physical therapy) eval for further PT needs. f/u (follow up) with Ortho in 4 weeks, f/u with PCP in 5-6 days. DME: has FWW (forward wheeled walker) and WC (wheelchair) at home. BIMS 15/15." A review of Patient 1's Discharge Planning/Discharge note dated January 2, 2024, at 12:57 pm by Licensed Vocational Nurse (LVN 1) indicated, "Patient was discharged @1257, patient c/o she is not ready to leave she is not able to walk. Patient was voice recording the entire discharge. She has requested all her medical records, medical records request has been sent…Went over my transition home with patient and a copy was provided to her, she declined to sign for a copy. A copy of her current medication was provided and explained (a blood thinner) was discontinued today, patient stated why isn't she going to be on DVT (deep vein thrombosis- blood clot in large vein) prophylaxis when she is home, this writer informed her she needs to follow-up with her PCP in 5-7 days and her provider will decide if she needs to be on it.” A further review of the discharge planning notes did not indicate a notice of discharge was provided to the long-term care Ombudsman on December 28, 2023, nor on January 2, 2024. On January 4, 2024, at 3:49 p.m., during an interview with the Case Manager (CM), she stated the facility did not issue a notice of transfer or discharge, only the NOMNC. She stated the nurse discharging the patient would be responsible for contacting the Ombudsman. On January 5, 2024, at 12:05 p.m., during a concurrent interview and record review with a Medical Record (MR) staff, the MR staff stated he had been working at the facility in medical records for three months, and he had not seen a Notice of Discharge or Transfer. He reviewed the physical chart for Patient 1 and stated there was no notice of transfer in the patient's record. On January 5, 2023, at 12:17 p.m., during an interview with Licensed Vocational Nurse (LVN 1), she stated she had been working at the facility for six months as an LVN. She stated she had discharged patients from the facility; and she stated the facility process for a facility-initiated discharge would be to get a physician's order, determine pick up time, and complete the “My Transition Home” (a document that recapitulates the patient's stay) with the patient. She stated she did not have to notify the Ombudsman. She speculated social services would be the one to inform the Ombudsman of the discharge. On January 5, 2024, at 12:27 p.m., during an interview with LVN 2, she stated during a facility initiated discharge the Ombudsman would be notified via phone call. She stated they would typically leave a message because the Ombudsman would not usually answer. She stated she did not document the notification. On January 5, 2024, at 12:33 p.m., during an interview with the Director of Nursing (DON 1), she stated for facility initiated discharges, the paperwork would be completed by the case manager. She stated other departments would document their input on the "My Transition" form (discharge summary). DON 1 stated the Ombudsman would be notified, however; she could not state if the Ombudsman notification would be documented. The DON was not familiar with a Notice of Discharge form nor its purpose. She stated notifications of discharge were done by the case manager. On January 8, 2024, at 4:25 p.m. during phone interview with Patient 1, she stated the facility provided a NOMNC, but did not provide a notice of transfer. On January 9, 2023, at 9:15 a.m. during an interview with the Ombudsman, she stated the facility has not been notifying the Ombudsman office of discharges. She stated it was discovered by the facility that the facility was emailing notifications to an Ombudsman's email who left the position in November 2023. She stated she was not notified of Patient 1's discharge. She stated she was made aware of the discharge when she received the SOC 341 form (form used to report an elder abuse) from the complaint. She stated there was no way to verify the notifications. On January 23, 2024, at 11:15 a.m. during an interview with the Ombudsman, she stated the facility sent the notifications of December discharges to her office. She stated she has not received any notices of facility-initiated discharges since November. She stated the notifications started after Patient 1's discharge (discharged on January 2, 2024). On February 21, 2024, at 1 p.m., during an interview, DON 2 stated the facility did not have the notice of the discharge/transfer documents on discharges for December 2023. She stated the documents must have been under the facility's previous administration. A review of the facility report dated January 22, 2024, was conducted. The report indicated “Discharge Date” and “Deceased Date” for patients discharged in December 2023, and the report indicated 30 patients were discharged to home, to another skilled nursing facility, or to an assisted living facility. A review of Patient 2’s admission record indicated the resident was admitted to the facility on November 20, 2023, and discharged home on December 1, 2023. A review of Patient 3’s admission record indicated the patient was admitted to the facility on October 25, 2023, and discharged to a board and care facility on December 2, 2023. A review of Patient 4’s admission record indicated the patient was admitted to the facility on November 7, 2023, and discharged home on December 4, 2023. A review of Patient 5’s admission record indicated the patient was admitted to the facility on November 1, 2023, and discharged home on December 4, 2023. A review of Patient 6’s admission record indicated the patient was admitted to the facility on November 5, 2023, and discharged home on December 4, 2023. A review of Patient 7’s admission record indicated the patient was admitted to the facility on November 11, 2023, and discharged home on December 5, 2023. A review of Patient 8’s admission record indicated the patient was admitted to the facility on November 14, 2023, and discharged home on December 6, 2023. A review of Patient 9’s admission record indicated the patient was admitted to the facility on November 21, 2023, and discharged home on December 7, 2023. A review of Patient 10’s admission record indicated the patient was admitted to the facility on November 21, 2023, and discharged home on December 7, 2023. A review of Patient 11’s admission record indicated the patient was admitted to the facility on November 25, 2023, and discharged home on December 9, 2023. A review of Patient 12’s admission record indicated the patient was admitted to the facility on December 8, 2023, and discharged home on December 11, 2023. A review of Patient 13’s admission record indicated the patient was admitted to the facility on November 23, 2023, and discharged home on December 13, 2023. A review of Patient 14’s admission record indicated the patient was admitted to the facility on December 2, 2023, and discharged home on December 15, 2023. A review of Patient 15’s admission record indicated the patient was admitted to the facility on November 29, 2023, and discharged home on December 15, 2023. A review of Patient 16’s admission record indicated the patient was admitted to the facility on November 13, 2023, and discharged home on December 16, 2023. A review of Patient 17’s admission record indicated the patient was admitted to the facility on December 4, 2023, and discharged home on December 16, 2023. A review of Patient 18’s admission record indicated the patient was admitted to the facility on December 5, 2023, and discharged home on December 19, 2023. A review of Patient 19’s admission record indicated the patient was admitted to the facility on December 6, 2023, and discharged home on December 19, 2023. A review of Patient 20’s admission record indicated the patient was admitted to the facility on December 10, 2023, and discharged home on December 19, 2023. A review of Patient 21’s admission record indicated the patient was admitted to the facility on December 1, 2023, and discharged home on December 20, 2023. A review of Patient 22’s admission record indicated the patient was admitted to the facility on November 25, 2023, and discharged home on December 21, 2023. A review of Patient 23’s admission record indicated the patient was admitted to the facility on December 12, 2023, and discharged home on December 22, 2023. A review of Patient 24’s admission record indicated the patient was admitted to the facility on December 20, 2023, and discharged to another skilled nursing facility on December 22, 2023. A review of Patient 25’s admission record indicated the patient was admitted to the facility on December 8, 2023, and discharged home on December 23, 2023. A review of Patient 26’s admission record indicated the patient was admitted to the facility on December 13, 2023, and discharged home on December 24, 2023. A review of Patient 27’s admission record indicated the patient was admitted to the facility on December 15, 2023, and discharged home on December 27, 2023. A review of Patient 28’s admission record indicated the patient was admitted to the facility on November 15, 2023, and discharged home on December 29, 2023. A review of Patient 29’s admission record indicated the patient was admitted to the facility on December 9, 2023, and discharged home on December 30, 2023. A review of Patient 30’s admission record indicated the patient was admitted to the facility on December 7, 2023, and discharged to an assisted living facility on December 30, 2023. As of February 21, 2024, no documentation indicating the Ombudsman were provided notice of the discharge for 30 residents (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30), were received from the facility. A review of the facility's' policy and procedure titled "Interdisciplinary Care Transition Checklists" dated April 2022 indicated under the section titled, "Transition from Skilled Nursing Facility to Home or other non-institutional setting" indicated, "On the day of discharge...Notify the ombudsman and complete Ombudsman Discharge Notification UDA." It was determined that the facility failed to ensure a copy of the written notice of transfer or discharge was provided to the long-term care Ombudsman for 30 of 50 patients, who were transferred and discharged from the facility between December 1, 2023, and January 2, 2024, in accordance with the facility policy and procedure. This failure had the potential to result in the discharged patients experiencing an inappropriate transfer or discharge and to not have the opportunity to speak with the Ombudsman to advocate in protecting the patient's rights from being inappropriately transferred or discharged. This violation had a direct or immediate relationship to the health, safety, security of the patients.