Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the representative of the Office of the State Long-Term Care Ombudsman regarding the unplanned hospital transfers of a resident, identified as Resident R102. This resident was initially admitted to the facility with multiple diagnoses, including spastic quadriplegia, cerebral palsy, major depressive and anxiety disorder, and dysphagia. On two separate occasions, July 7, 2024, and December 18, 2024, Resident R102 was transferred to the hospital due to medical needs, including a surgical gastrostomy and stomach pain, respectively. Despite these transfers, the facility did not provide the required written notices to the State Long-Term Care Ombudsman. This oversight was confirmed by the Nursing Home Administrator on March 20, 2025, indicating a failure to comply with the regulatory requirement to notify the Ombudsman of such transfers, as stipulated in the relevant sections of the Code of Federal Regulations and Pennsylvania Code.
Plan Of Correction
1. The Office of the Ombudsman was notified that R102 was discharged to the hospital on 7/7/24 and that R102 was discharged to the hospital on 12/18/24 and that these residents were left off due to incorrect report pulled. 2. Correct Report pulled from PCC that included bed holds for residents discharged from 1/1/25 to current and resent to the Office of the Ombudsman. 3. Education provided to Social Services and Clinical Mgt Staff on what report to pull and that should include bed holds. 4. Random audits by the Administrator/designee of all discharges to ensure all are on the notification sent to Office of the Ombudsman once a week for three months. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.