Health inspection·November 21, 2024

Complaint # CA00923921 Health and Safety Code- 1439.6 (a) (c) (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. (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 based on interview and record review, the facility failed to ensure a copy of the discharge notice was sent to the Long-Term Care (LTC) Ombudsman the same time the discharge notice was provided to Patient 4. This failure had the potential for the Ombudsman not to be able to advocate for Patient 4 to ensure a safe and appropriate discharge. A review of Patient 4's admission record indicated Patient 4 was admitted to the facility on September 20, 2024, with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a cerebral infarction (stroke). Patient 4 was discharged on October 9, 2024. A review of Patient 4's "Order Summary Report," for the month of October 2024, indicated, "...LCD (last cover day) 10/8/24 discharge 10/9/24..." A review of Patient 4's "NOTICE OF TRANSFER/DISCHARGE," signed by the facility representative on October 9, 2024, indicated, "...Notification date: 10/1/2024...Effective Date: 10/9/2024...This notice is to inform you that transfer/discharge is necessary for the following reason...The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by the facility..." The discharge notice indicated a copy was sent to the State LTC Ombudsman on October 11, 2024. A review of Patient 4's "Progress Notes," dated October 9, 2024, at 1:10 p.m., indicated, "DC (discharge) for (sic) doctors order, went home with (family member)..." On October 10, 2024, at 3:30 p.m., an interview was conducted with Social Service Designee (SSD) 1. SSD 1 stated discharge and transfer notices were sent to the Ombudsman by email on the first of the month. SSD 1 stated there was no way to send them every day prior to the patient’s being discharged. On October 10, 2024, at 5:16 p.m., an interview was conducted with SSD 2. SSD 2 stated Patient 4 was discharged on October 9, 2024. SSD 2 stated that Patient 4’s discharge notice had not been sent to the Ombudsman’s office yet. A review of the facility’s policy and procedure titled, "Transfer or Discharge, Facility-Initiated," revised October 2022, indicated,"...Facility-Initiated Transfer or Discharge...'Facility-initiated transfer or discharge' means a transfer or discharge which the Resident objects to, or did not originate through a Resident's verbal or written request...Notice of Transfer or Discharge (Planned)...3. 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..." Based on interview and record review, the facility failed to ensure a copy of the discharge notice was sent to the LTC Ombudsman the same time the discharge notice was provided to Patient 4. This failure had the potential for the Ombudsman not to be able to advocate for Patient 4 to ensure a safe and appropriate discharge. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.