Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to comply with federal regulations regarding the notification of the Office of the State Long-Term Care Ombudsman before transferring or discharging residents. Specifically, the facility did not provide transfer notices to the Ombudsman for the entire year of 2024, as confirmed by the Nursing Home Administrator during an interview. This deficiency was identified through a review of the facility's policy on 'Transfer and Discharge' and the relevant federal regulations, which mandate that a copy of the transfer or discharge notice must be sent to a representative of the Ombudsman. The facility's policy indicated that no resident would be discharged without timely notification to the resident, responsible party, or authorized representative. However, the facility did not adhere to the requirement of notifying the Ombudsman, which is a critical step in the transfer or discharge process. This oversight was consistent across all months from January to December 2024, indicating a systemic issue in the facility's compliance with the notification requirements outlined in §483.15(c)(3).
Plan Of Correction
1. The facility will provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division. The facility cannot retroactively address the concern identified during the annual survey. 2. The facility will send the discharge/transfer list to the state Ombudsman monthly. 3. The Nursing Home Administrator or Designee will re-educate the Director of Social Services on federal tag 0623. 4. The Nursing Home Administrator or Designee will complete an audit monthly for three months to validate the transfer/discharge list is completed and sent to the state Ombudsman monthly. 5. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.