F0628

D

Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices

Brea, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required written notices of transfer/discharge, including appeal rights and bed-hold information, to residents or their representatives. Facility policy titled “Transfer Discharge Bed-Hold Procedure” required that the patient and, if known, the family member, surrogate, or legal representative be notified at least 30 days prior to transfer when applicable, and that the written notice include the reason for transfer/discharge, effective date, new location, appeal rights, and contact information for the state LTC ombudsman and protection and advocacy agencies. Surveyors found that for two of three sampled residents reviewed for transfer and discharge, these written requirements were not met.

For one resident (Resident 39), the medical record showed admission in October 2025 and a physician’s order dated 11/11/25 for discharge to an assisted living facility. The H&P documented that this resident had capacity to understand choices and make health care decisions. Progress notes on 11/11/25 recorded that the resident was transferred to an assisted living facility. A Notice of Transfer/Discharge dated 11/11/25 identified the assisted living facility as the transfer location and stated that the resident’s health had improved sufficiently so that facility services were no longer required. The notice form contained language about the right to appeal an involuntary or inappropriate transfer/discharge and listed the DHCS Office of Administrative Hearings and Appeals, the state LTC ombudsman, and state agencies for developmentally disabled and mentally ill individuals, along with instructions to file an appeal within 10 calendar days. However, the section for the resident or representative signature indicated only that the notice was provided to the resident’s representative via telephone and did not contain a representative’s signature, and there was no documentation that a written copy of the notice was provided to the resident or representative.

During interviews regarding Resident 39, RN 3 confirmed that the resident was discharged to assisted living on 11/11/25 and that the representative was informed of the transfer/discharge via telephone. RN 3 stated she was not aware whether the facility mailed written Notices of Transfer/Discharge when residents were transferred or discharged and could not verify that a written notice was provided to Resident 39’s representative. The Medical Records Director reported that she faxed the Notice of Transfer/Discharge to the ombudsman but did not mail written notices if the resident or representative was unable to sign at the time of transfer or discharge, and she verified that she did not mail a written notice to Resident 39’s representative.

For another resident (Resident 42) on the Subacute Unit (SAU), the facility’s SAU Transfer, Discharge, Bed-hold Procedure required that at the time of transfer/discharge, the patient and family member or legal representative receive a written notice of the bed-hold policy specifying the duration of the bed hold and readmission criteria. The policy also required that if a patient transferred with an expectation of return could not return, the SAU must provide written notice of transfer/discharge and reasons, send a copy to the state LTC ombudsman, and include appeal rights and contact information for the appeal entity, ombudsman, and protection and advocacy agencies. Resident 42’s record contained a Notice of Transfer/Discharge dated 1/12/26 indicating transfer to an acute care hospital because the transfer or discharge was necessary for the resident’s welfare and the needs could not be met in the facility. An SAU Form–Notice of Bedhold dated the same day showed the resident left for hospitalization and elected to hold the bed for a specified period.

Progress notes for Resident 42 documented that Family Member 2 was called on 1/12/26 to inform them of the transfer to the acute care hospital. The Notice of Transfer/Discharge for that date indicated on the resident/resident representative signature line that Family Member 2 was informed via telephone of the transfer. The content of the notice included the reason for transfer and information about the appeal process if the resident or representative believed the discharge was inappropriate or involuntary. However, in a telephone interview, Family Member 2 stated they did not receive a copy of the Notice of Transfer/Discharge and were not aware of its contents. RN 3 stated that the notice was given to medical records staff and that nursing staff did not mail notices. The Medical Records Director stated she did not mail a copy of the notice of transfer/discharge to Resident 42’s responsible party and believed nursing staff mailed such notices. As a result, the resident’s interested parties did not receive the complete written information related to the transfer/discharge process, including appeal rights and bed-hold policy, as required by facility policy and regulation.