Other·February 7, 2024

42 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. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when— (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. On 12/15/2023, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about transfer and discharge. The facility failed to ensure a copy of the resident's written notice of the proposed discharge was provided to the Office of the State Long-Term Care (LTC) Ombudsman (assist residents in LTC facilities with issues related to day-to-day care, health, safety, and personal preferences) at the same time the notice is sent to the residents or the resident’s representative before transfer or in emergency situations as soon as practicable for Resident 6, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, and Resident 14. As a result, Resident 6, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, and Resident 14 were denied protection and advocacy in the event residents were inappropriately or involuntary transferred from the facility. 1. A review of Resident 6’s Admission Record indicated the facility admitted the resident on 10/18/2023. A review of Resident 6’s physician order dated 11/20/2023, indicated that the physician ordered Resident 6 to discharge home with a home health (a nursing specificality in which a nurse provides resident care at the resident’s home) referral on 11/20/2023. A review of Resident 6’s Notice of Proposed Transfer/Discharge (NOPT/D) indicated that the Notification Date to Resident 6 was on 11/20/2023. A review of Resident 6’s Discharge Summary and Post-Discharge Plan of Care (Discharge Summary) dated 11/20/2023, indicated that Resident 6 was discharged home on 11/20/2023. The reason for discharge indicated that Resident 6’s health had improved sufficiently. Resident 6 no longer needed the services of the facility. A review of the facility fax verification indicated that the facility faxed Resident 6’s copy of NOPT/D dated 11/20/2023 to the LTC Ombudsman on 12/11/2023 at 4:12 p.m. 2. A review of Resident 8’s Admission Record indicated the facility admitted the resident on 8/7/2023. A review of Resident 8’s physician order dated 8/29/2023, indicated that the physician ordered Resident 8 to discharge home on 8/24/2023 with home health services. A review of Resident 8’s NOPT/D indicated that the Notification Date was 8/24/2023. A review of Resident 8’s Discharge Summary dated 8/24/2023, indicated that Resident 8 was discharged home on 8/24/202. The reason for discharge indicated that Resident 8’s health had improved sufficiently, and that Resident 8 no longer needed the services of the facility. A review of the facility fax verification indicated that the facility faxed Resident 8’s copy of NOPT/D dated 8/24/2023 to the LTC Ombudsman on 9/1/2023 at 5:06 p.m. 3. A review of Resident 9’s Admission Record indicated the facility admitted the resident on 7/3/2023 and readmitted on 7/31/2023. A review of Resident 9’s physician order dated 8/24/2023, indicated that the physician ordered Resident 9 to be discharge home on 8/25/2023 with home health services. A review of Resident 9’s NOPT/D indicated that the Notification Date was 8/29/2023. A review of Resident 9’s Discharge Summary dated 8/29/2023, indicated, Resident 9 was discharged home on 8/24/2023. The reason for discharge indicated that Resident 9’s health had improved sufficiently, and the resident no longer needed the services of the facility. A review of the facility fax verification indicated that the facility faxed Resident 9’s copy of NOPT/D dated 8/29/2023 to the LTC Ombudsman on 9/1/2023 at 5:06 p.m. 4. A review of Resident 10’s Admission Record indicated the facility admitted the resident on 9/5/2023. A review of Resident 10’s physician order dated 9/13/2023, indicated that the physician ordered Resident 10 to be discharge home on 9/17/2023 with home health services. A review of Resident 10’s NOPT/D indicated that the Notification Date was 9/13/2023. A review of Resident 10’s Discharge Summary dated 8/29/2023, indicated, Resident 10 was discharged home on 8/24/2023. The reason for discharge indicated that Resident 10’s health had improved sufficiently, and that the resident no longer needed the services of the facility. A review of the facility fax verification indicated that the facility faxed Resident 10’s copy of NOPT/D date 9/13/2023 to the LTC Ombudsman on 10/3/2023 at 1:53 p.m. 5. A review of Resident 11’s Admission Record indicated the facility admitted the resident on 9/9/2023. A review of Resident 11’s physician order dated 9/20/2023, indicated that the physician ordered Resident 11 to be discharge home on 9/21/2023 with home health services. A review of Resident 11’s NOPT/D indicated that the Notification Date was 9/20/2023. A review of Resident 11’s Discharge Summary dated 9/21/2023, indicated, Resident 11 was discharged home on 9/21/2023. The reason for discharge indicated that Resident 11’s health had improved sufficiently, and that the resident no longer needed the services of the facility. A review of the facility fax verification indicated that the facility faxed Resident 11’s copy of NOPT/D dated 9/20/2023 to the LTC Ombudsman on 10/3/2023 at 1:53 p.m. 6. A review of Resident 12’s Admission Record indicated the facility admitted the resident on 9/27/2023. A review of Resident 12’s physician order dated 10/15/2023, indicated that the physician ordered Resident 12 to be discharge home on 9/21/2023 with home health services. A review of Resident 12’s NOPT/D indicated that the Notification Date was 10/15/2023. A review of Resident 12’s Discharge Summary dated 10/15/2023, indicated that Resident 12 was discharged home on 10/15/2023. The reason for discharge indicated that Resident 12’s health had improved sufficiently, and that the resident no longer needed the services of the facility. A review of the facility fax verification indicated that the facility faxed Resident 12’s copy of NOPT/D dated 10/15/2023 to the LTC Ombudsman on 11/13/2023 at 3:58 p.m. 7. A review of Resident 13’s Admission Record indicated the facility admitted the resident on 9/29/2023. A review of Resident 13’s physician order dated 10/18/2023, indicated that the physician ordered Resident 13 to be discharge home on 10/16/2023 with home health services. A review of Resident 13’s NOPT/D indicated that the Notification Date was 10/16/2023. A review of Resident 13’s Discharge Summary dated 10/16/2023, indicated Resident 13 was discharged home on 10/16/202. The reason for discharge indicated that Resident 13’s health had improved sufficiently, and that the resident no longer needed the services of the facility. A review of the facility fax verification indicated that the facility faxed Resident 13’s copy of NOPT/D dated 10/16/2023 to the LTC Ombudsman on 11/13/2023 at 3:58 p.m. 8. A review of Resident 14’s Admission Record indicated the facility admitted the resident on 5/18/2023 and readmitted on 10/12/2023. A review of Resident 14’s physician order dated 11/13/2023, indicated that the physician ordered Resident 14 to be discharge home on 11/14/2023 with home health services. A review of Resident 14’s NOPT/D indicated that the Notification Date was 11/13/2023. A review of Resident 14’s Discharge Summary dated 11/14/2023, indicated that Resident 14 was discharged home on 11/14/2023. The reason for discharge indicated that Resident 14’s health had improved sufficiently, and that the resident no longer needed the services of the facility. A review of the facility fax verification indicated that the facility faxed Resident 14’s copy of NOPT/D dated 11/13/2023 to the LTC Ombudsman on 12/11/2023 at 4:12 p.m. During an interview on 12/19/2023 at 9:04 a.m., the Social Services Director stated that the facility faxes the copies of resident’s NOPT/D to the LTC Ombudsman monthly at the end of each month for all facility-initiated transfers/discharges (transfers or discharges which the resident objects to, or did not originate through a resident’s verbal or written request) and resident-initiated transfers/discharges (the resident or the resident representative has provided verbal or written notice of intent to leave the facility). During an interview on 12/19/2023 at 12:05 p.m., the Director of Nursing (DON) stated that the facility should have faxed Resident 6, 8, 9, 10, 11, 12, 13, and 14’s NOPT/D to the LTC Ombudsman on the same day that the facility issued NOPT/Ds to the residents. The DON stated that sending a resident’s NOPT/D to the LTC Ombudsman only once monthly is the incorrect practice. The DON stated that the LTC Ombudsman needs to be notified as soon as possible to ensure safe discharges for the residents. During an interview on 12/22/2023 at 3:17 p.m., the Administrator (ADM) stated that the facility did not have a specific policy and procedure for sending a resident’s NOPT/D to the Ombudsman Office. The facility failed to ensure a copy of the resident's written notice of the proposed discharge was provided to the Office of the State LTC Ombudsman at the same time the notice is sent to the residents or the resident’s representative before transfer or in emergency situations as soon as practicable for Resident 6, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, and Resident 14. As a result, Resident 6, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, and Resident 14 were denied protection and advocacy in the event residents were inappropriately or involuntary transferred from the facility. The above violations had a direct relationship to the health, safety, or security of Resident 6, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, and Resident 14.