Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided with written notification of transfer or discharge, including sending a copy to the Ombudsman, as required by regulations. This deficiency was identified during a survey conducted from January 22 to January 30, 2025, involving a resident who was transferred to the hospital. The facility did not have a documented policy addressing the notification process for residents, their representatives, and the Ombudsman regarding the reasons for hospital transfers. The specific case involved a resident admitted with diagnoses of Anemia, Coronary Artery Disease, and Hypertension. On December 25, 2024, the resident experienced several episodes of vomiting and diarrhea, prompting a physician to order a hospital transfer. Although the family was notified, there was no documented evidence that the Ombudsman was informed of the transfer. The Director of Social Work acknowledged the oversight, stating that notices were only sent if a resident was admitted to the hospital, not if they were sent to the emergency room and returned without admission.
Plan Of Correction
Plan of Correction: Approved March 18, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: In the facility policy it states inform the family/representative and Ombudsman regarding facility's bedhold with 72 hours; however, resident #127 was not admitted and returned to the facility within twenty-four hours. The resident was not negatively impacted by this deficient practice. 2. How will The New Jewish Home Sarah Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? A monthly transfer and discharge binder was developed by the Social Worker to cross-reference and ensure all notifications were included in a report at least monthly to the Office of State LTC Ombudsman. Copies of sent emails will be stored in this binder as evidence of compliance. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? Sarah Neuman reviewed and revised the Bed Hold Discharge Transfer Retention Notice Policy to ensure notices before transfer are issued and that the Office of State LTC Ombudsman is notified in a timely manner. The Bedhold retention notification and the Hospital transfer notice have been combined into one notification document. The Director of Social Work provided training and education on the updated policy to Social Workers, Nursing Managers, and Unit Clerks. 4. How will The New Jewish Home Sarah Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change)? The Director of Social Work and/or designee will conduct audits monthly on the timely notification to the Office of State LTC Ombudsman and provide a report of the audit findings to the QAPI committee monthly for 3 months, then quarterly for action as appropriate.