Other·May 23, 2024

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. Code of Federal Regulations, Title 42, §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a patient, the facility must: (i) Notify the patient and the patient’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 March 15, 2024, at 10:00 a.m., an unannounced visit was made to the facility to investigate a quality-of-Care 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. Patient 1 received the notice of discharge on March 11, 2024. This failure has the potential for the Ombudsman not to be able to advocate for Patient 1 in protecting the patient's rights from an inappropriate transfer and discharge. A review of Patient 1’s face sheet, indicated the patient was admitted to the facility on February 23, 2024, with diagnoses which included cerebral infarction (damage to the tissue in the brain due to a loss of oxygen to the area). A review of Patient 1’s “Discharge Summary,” dated March 19, 2024, at 8:53 a.m., indicated the patient was discharged from the facility on March 19, 2024, at 10:00 a.m. On March 15, 2024, at 10:51 a.m., during interview with the Social Services Director (SSD), she stated the patient and/or patient’s representative are notified of their pending discharge using the “Notice of transfer/discharge" form. The SSD stated the patient or the patient's representative would sign and would be provided a copy of the notice, at the time of the discharge notification. The SSD further stated, every end of the month, a copy of all the notice of transfer/discharges are faxed to the Ombudsman. On March 15, 2024, at 3:57 p.m., during interview with Licensed Vocational Nurse (LVN) 1, she stated at the time of discharge, the patient would be provided with a copy of their notice of discharge, then a copy is placed in the Social Services box, to be faxed to the Ombudsman. On April 3, 2024, at 9:15 a.m., during interview with the Administrator, he stated the SSD was notifying the Ombudsman of facility-initiated discharges once a month, and not at the time the patient was notified of their pending discharge. On April 9, 2024, at 3:50 p.m., during interview with the SSD, she stated the Ombudsman was provided notification of all the March facility-initiated discharges in one fax transaction on April 1, 2024. However, she stated the facility did not keep copies of the fax confirmation. A review of the facility policy and procedure titled, “Transfer or Discharge Notice,” revised, December 2016, indicated, “… 4. A copy of the notice (of discharge) will be sent to the Office of the State Long-Term Ombudsman on monthly basis …” A review of the facility policy and procedure titled, "Notification to Ombudsman of Transfer and Discharge," revised April 2017, indicated, "...Resident discharge to home or other entity...Social Services...will provide notice of discharge...Social services...will ensure receipt of signed notice of discharge...Social Services...will fax notification to Ombudsman...Social Services...to ensure delivery of notice to Ombudsman...Resident transfer to hospital...Social services...will send notification report to Ombudsman at a routine interval established by facility (monthly)..." A review of the policies and procedures titled, "Transfer or Discharge Notice," revised December 16, 2016, and "Notification to Ombudsman of Transfer and Discharge," revised April 2017, did not reflect what was required under the statute, Health and Safety Code 1439.6 (a), which stipulated that for facility initiated discharge or transfer, a copy of the transfer or discharge notice should be provided to the office of the LTC Ombudsman at the same the notice was given to the patient or the patient's 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 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 Patient 1 in protecting patient's rights from inappropriate transfer and discharge. This violation had a direct or immediate relationship to the health, safety, security of Patient 1.