Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for a period exceeding two years, from September 12, 2022, through November 6, 2024, as required by regulations. This deficiency was identified through a review of facility documents, information from the State Ombudsman Office, and staff interviews. On December 19, 2024, a request to review the facility's compliance documents revealed a lack of documented evidence of notifications to the Ombudsman Office during the specified period. Additionally, information from the State Ombudsman Office on August 1, 2024, confirmed the facility's failure to notify since September 12, 2024, and an updated list on December 3, 2024, indicated that while the facility had started notifying, the information provided was incomplete. The Nursing Home Administrator and Vice-President of Clinical confirmed the failure to report during an interview on December 19, 2024.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: The State Long-Term Care Ombudsman was notified via monthly list for December 2024, sent on January 7, 2025, by the Social Services Director. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents who have been transferred or discharged have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Administrator, with all social services staff addressing circumstances regarding required notice of resident discharges/transfers to The State Long-Term Care Ombudsman. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: For a period of four weeks, the Social Service Director, or designee, will conduct a record audit of all residents who have been transferred or discharged. The audit will be monthly after the first four-week period. A transfer/discharge list will be sent to the State Ombudsman Office monthly via email and a copy retained for facility records. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.