Failure to Notify State Ombudsman of Transfers/Discharges
Penalty
Summary
The facility failed to comply with the regulatory requirement to notify the State Ombudsman Office of resident transfers and discharges over an eight-month period. This deficiency was identified through a review of facility documents, an audit conducted by the State Ombudsman Office, and staff interviews. The review period spanned from June 2024 to January 2025, during which the facility did not provide documented evidence of notifying the State Ombudsman Office as required by the regulations. The Director of Nursing confirmed during an interview that the facility did not report resident transfers and discharges to the State Ombudsman Office for the specified period. This lack of notification was corroborated by an audit conducted by the State Ombudsman Office, which also found that the facility failed to meet the notification requirements. The deficiency highlights a significant lapse in the facility's adherence to mandated communication protocols regarding resident transfers and discharges.
Plan Of Correction
January transfer/discharge list of residents was sent to the State Ombudsman on 2/24/2025. February transfer/discharge list will be sent by 3/14/2025 to the State Ombudsman Office. The policy on Transfer-Notification was explained by the Regional Director of Clinical Services to the Nursing Home Administrator on 2/13/2024. The Nursing Home Administrator/designee will be responsible for the notification process for notifying the State Ombudsman monthly by the 15th of each month. The transfer/discharge log will be e-mailed to the Regional Director of Clinical Services monthly, until deemed resolved by the QAPI committee.