Health inspection·July 31, 2025

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, that the facility failed to ensure a copy of the discharge notice was sent to the Long-Term Care (LTC) Ombudsman at the same time as the notice was provided to Patient 1. This failure had the potential for the LTC Ombudsman not to be able to advocate for the patient in protecting their rights from inappropriate transfer and discharge. On April 30, 2025, at 10:29 a.m., during an interview, Social Services Designee (SSD) 1 stated that the discharge notice for Patient 1 should be sent to the LTC Ombudsman office at the same time the discharge notice is sent to the patient or the patient’s representative, which should have been on April 22, 2025, for Patient 1. On April 30, 2025, at 10:54 a.m., during an interview, SSD 2 stated that the discharge notice for Patient 1 was provided to Patient 1's family member over the phone and a copy was provided to Patient 1, on April 22, 2025. SSD 2 stated that they sent the discharge notice to LTC Ombudsman on April 25, 2025, by fax (three days after the discharge notice was provided to Patient 1). A review of Patient 1's "Notice of Transfer / Discharge," issued on April 22, 2025, indicated,"...Notification Date: 4/22/25...Effective Date: 4/25/25...This notice to inform you that transfer/discharge is necessary for the following reasons...The transfer or discharge is appropriate because your health has improved sufficiently so you no longer require services by this facility...Copy of State LTC Ombudsman Office date: 4/25/25..." A review of Patient 1's "Progress Notes," dated April 25, 2025, at 3 p.m., indicated,"...Patient with an order to Discharge to home...Patient left the facility at around 3 pm pickup by [name of transportation company]..." A review of the facility policy and procedure titled, "Transfer or Discharge Notices," revised March 2025, indicated, "...Notice of Transfer or Discharge (Anticipated)...4. 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 at the same time the notice was provided to Patient 1. This failure had the potential for the LTC Ombudsman not to be able to advocate for the patient in protecting their rights from inappropriate transfer and discharge. This violation had a direct or immediate relationship to the health, safety, or security of patients.