Other·August 10, 2023

F623 §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 §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; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

F624 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. 22 CCR § 72519. Patient Transfer. (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. 22 CCR § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR §72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. On 6/13/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about the transfer and discharge of Resident 2. The facility failed to permit Resident 2 to remain in the facility and not transfer or discharge him unless the transfer / discharge was necessary and appropriate. The facility failed to: 1. Ensure the reason for discharging Resident 2 was because of one of the following: the resident's welfare and needs could not be met in the facility; his care needs could not be met at the facility, his health had improved and no longer needed the services provided by the facility, for the safety of individuals in the facility due to Resident 2's clinical or behavioral status, because of Resident 2's lack of payment, or because the facility ceased operation. 2. Ensure the attending physician (Physician 1) documented in Resident 2's clinical record the basis of the transfer / discharge. 3. Ensure Resident 2 was not transferred while an appeal hearing was pending. 4. Provide and document sufficient preparation and orientation to Resident 2 for a safe and orderly transfer or discharge from the facility. 5. Ensure Resident 2 was notified at least 30 days before the resident was transferred or discharged and the reasons for the move in writing and in a manner the resident understands. 6. Ensure a copy of the facility-initiated notice was sent to a representative of the Office of the State Long-Term Care Ombudsman (residents' advocate group). 7. Provide sufficient preparation to ensure a safe discharge for Resident 2, who had an unhealed left ischium (the lower part of the hip bone that supports a person while sitting, sometimes referred as the sit bone) pressure ulcer (a skin and soft tissue injury that forms as a result of constant or prolonged pressure exerted on the skin over bony areas) Stage IV (deep wound penetrates all three layers of skin, exposing muscles, tendons, and bones) and had a right lower leg cellulitis (a bacterial [group of single-cell microorganisms] infection, bacteria enter the skin and tissue through a wound and the treatment includes antibiotics; without treatment it can be life-threatening). 8. Implement its policies and procedures related to the transfer and discharge of residents. On 5/3/2023, the facility issued a Notice of Discharge to Resident 2 without an effective date or a location, since it was not until 6/5/2023 at 4:16 p.m., that the facility found out Board and Care #2 (“B&C #2,” a lower level of care senior living facility licensed to care for residents who need some assistance with activities of daily living [ADLs, such as eating, walking, transfer, dressing, and bathing] but do not provide medical or nursing care), was accepting Resident 2. The facility proceeded to transfer Resident 2 the following day, on 6/6/2023 to a lower level of care, a Board and Care facility where Resident 2's medical and nursing needs could not be met. As a result, Resident 2 was discharged hurriedly and on 6/11/2023, five days after discharge from the facility, Resident 2's condition deteriorated, where he developed untreated severe pain requiring B&C #2 staff to transfer Resident 2 to General Acute Care Hospital 1 (GACH 1). Resident 2 was admitted to GACH 1, the same day (6/11/2023), due to right lower leg wound infection and fever requiring intravenous (IV - through the vein) antibiotic (medication to fight bacterial infections) and IV Morphine (a narcotic medication [moderate doses dull the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions]. A review of Resident 2's Admission Record indicated the facility admitted the resident, a 63-year-old male, on 11/23/2022 with diagnoses including paraplegia (inability to move the lower half of the body including both legs), diabetes mellitus (group of diseases that result in too much sugar in the blood), polyneuropathy (a condition in which a person's nerves outside the brain and spinal cord are damaged; it affects the nerves in the skin, muscles, and organs), hypertension (abnormally elevated blood pressure), a right lower leg cellulitis, and unhealed left ischium pressure ulcer (a skin and soft tissue injury that forms as a result of constant or prolonged pressure exerted on the skin over bony areas) Stage IV (deep wound penetrates all three layers of skin, exposing muscles, tendons, and bones). A review of Resident 2's History and Physical exam dated 12/16/2022, indicated the resident had the capacity to understand and make decisions. A review of the Physician's Orders for Resident 2, dated 12/16/2022 and clarified on 4/11/2023, indicated to provide daily indwelling urinary catheter (a soft tubing inserted into the bladder draining urine into a bag outside the body) care; change the catheter and drainage bag if dislodged or malfunction; monitor for signs and symptoms of infection every shift; monitor for pain; and irrigate with 30 to 60 milliliters (ml - unit of measure) as needed for heavy sediments (minerals in the urine) or blockage. A review of the Physician's Order for Resident 2, dated 12/22/2022, indicated the use of a low air loss mattress (an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and wicks away any moisture) for wound management, check placement, functioning, and settings every shift. A review of the Physician's Order for Resident 2, dated 12/27/2022, indicated to monitor the resident for pain before and after wound treatment. A review of the Physician's Order for Resident 2, dated 1/19/2023, indicated to give gabapentin (medication used for nerve pain, which can be caused by different conditions after an injury) 300 milligrams (mg) one capsule by mouth four times a day for neuropathic pain (happens when the nervous system is damaged or not working correctly). According to a review of the Physician's Order, dated 3/2/2023, Resident 2 was to receive nortriptyline (medication used for nerve pain) 25 mg by mouth every night. A review of the form Notice of Transfer / Discharge to Resident 2 with notification date of 5/3/2023, indicated the resident was self-responsible and the effective date of discharge was 6/6/2023 to B&C #2 (this date and the specific B&C were not known on 5/3/2023). The reason for discharge was, "because your health has improved sufficiently so that you no longer require services provided by this facility." The Notice also indicated by handwritten note that the discharge was “per the resident’s request.” A review of the form Notice of Proposed Transfer and Discharge to Resident 2 dated and signed by a facility representative on 5/10/2023 and hand-delivered to the resident, who did not sign the form, indicated a discharge effective date of 6/9/2023 to B&C #1. The reasons for discharge were: - The discharge is nec