Health inspection·April 6, 2023

Murrieta Health and Rehabilitation Center Event: DPRX11 Surveyor 48422, HFEN Class "B" citation 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. (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. (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. (d) For the purposes of this section, a "facility-initiated transfer or discharge" is a transfer or discharge that is initiated by the facility and not by the resident, whether or not the resident agrees to the facility's decision. CFR 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 December 14, 2022, at 1:50 p.m., an unannounced visit to the facility was conducted to investigate a quality care issue. It was determined that the facility failed to ensure a copy of the written notice of transfer or discharge was provided to the Local Long-Term Care Ombudsman when Patient 2 was transferred to the General Acute Care Hospital (GACH) on November 23, 2022. This failure placed Patient 2 at an increased risk of being transferred without having an advocate to ensure a safe and effective transition of care, or without having a clear understanding of his appeal and transfer rights. On December 14, 2022, Patient 2's medical records were reviewed. Patient 2 was admitted to the facility on March 11, 2022, with diagnoses of fracture of right and left femur (hip fracture), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). A review of Patient 2's "History and Physical" dated March 13, 2022, indicated she had the capacity to understand and make decisions. A review of Patient 2's "Change in Condition Evaluation" dated November 23, 2022, at 2 p.m., indicated "...Abrupt onset of painful urination with or without fever...Recommendation of Primary Clinician(s): send to ER for further evaluation or treatment..." A review of Patient 2's "Order Summary Report" dated November 23, 2022, indicated, "...Bed hold x 7 days sent to the hospital for further evaluation and treatment starting 11/23/22..." On February 23, 2023, at 2:25 p.m., an interview was conducted with the Medical Record Director (MRD). The MRD stated the nurses were supposed to fill out the Transfer or Discharge notice to the Ombudsman, and the medical records department would fax the completed form to the local long-term Ombudsman office. The MRD stated she was not sure if Patient 2's transfer notification was faxed to the Ombudsman office. On February 23, 2023, at 3:10 p.m., a telephone interview was conducted with the MRD. The MRD stated that there was no record of the transfer notification to the Ombudsman for Patient 2. A review of the facility's policy and procedure titled, "Transfer or Discharge, Facility-Initiated" dated October 2022, indicated, "...Notice of Transfer or Discharge (Emergent or Therapeutic Leave)...When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers...Notice of Transfer is provided...to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements)..." Based on interview and record review, the facility failed to ensure a copy of the written notice of transfer or discharge was provided to the Local Long-Term Care Ombudsman when Patient 2 was transferred to the GACH on November 23, 2022. This failure placed Patient 2 at an increased risk of being transferred without having an advocate to ensure a safe and effective transition of care, or without having a clear understanding of his appeal and transfer rights. This violation of the regulations had a direct or immediate relationship to the health, safety, or security of the patient.