Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of a discharge for a resident, which was identified during a review of records and staff interviews. The resident, who had multiple diagnoses including acute on chronic systolic heart failure, cellulitis, bacteremia, chronic kidney disease, and pleural effusion, was discharged home under hospice care. The discharge summary indicated that the resident's spouse signed the discharge papers and reviewed the medications. However, the required notification to the Ombudsman was not documented, as the relevant sections on the discharge notice form were left blank. During an interview, the Social Services Director confirmed the facility's responsibility to notify the Ombudsman of discharges and admitted to not retaining the fax confirmation page as proof of notification. A subsequent interview with the Ombudsman confirmed that they had not been notified of the resident's discharge. The facility's policy on post-discharge planning did not appear to have been followed in this instance, as there was no verification of the Ombudsman being contacted, which is a critical step in the discharge process.
Plan Of Correction
of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483. 1. On 2/27/25, Office of the Ombudsman notified of resident # 104's discharge by the Social Service Director. 2. On 3/21/25, the Social Services Director/Designee completed a review of residents discharged in the last 30 days to verify ombudsman notified as required. Follow up based on findings. The review revealed the February log was incomplete and the March logs were still in progress. The February log was updated and an accurate listing was sent to the Office of the Ombudsman. 3. On 3/21/25, the Administrator/Designee completed education with Social Services employees regarding ombudsman notification of resident discharge/transfer. 4. Social Services Director/Designee to complete weekly monitoring of resident discharge/transfers to ensure ombudsman notification completed as required for a period of 3 months or until substantial compliance achieved, then quarterly and as needed. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications implemented as indicated.