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F0551
D

Failure to Notify Responsible Party of Discharge Delay and Inadequate Voicemail Monitoring

Los Angeles, California Survey Completed on 07-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify and update a resident's responsible party (RP) regarding a significant delay in the resident's transportation for discharge. The resident, who was cognitively intact and dependent on staff for several activities of daily living, was scheduled for discharge home with transportation initially set for the morning but delayed multiple times throughout the day. Although the resident was informed of the new transportation time, the RP was not notified of the changes, resulting in the RP waiting and becoming worried when the resident did not arrive home as expected. The RP made several attempts to contact the facility, leaving voicemails that were not reviewed or responded to by staff. Interviews with facility staff revealed that no one was assigned to check the facility's voicemail system, and several staff members, including the receptionist, RN supervisor, and DON, stated they did not know how to retrieve voicemail messages. Facility policy required prompt notification of changes in a resident's condition or status to the resident and their representative, but this was not followed. The lack of communication led to the resident feeling anxious about going home and the RP experiencing distress due to the lack of information.

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