Failure to Notify LTC Ombudsman of Facility-Initiated Discharges and Transfers
Penalty
Summary
The facility failed to notify and provide evidence that the LTC Ombudsman was given a copy of the transfer notice for 42 out of 42 residents who were subjected to a facility-initiated discharge or transfer to the hospital between December 2024 and March 2025. Multiple staff interviews, including those with the program director, nurse manager, licensed nurses, and the social services director, confirmed that the behavioral unit had never notified the ombudsman of any discharges or transfers to the hospital. Staff members indicated that they were either unaware of the requirement or believed it was not necessary to notify the ombudsman. A review of facility policy and the All Facilities Letter (AFL 17-27) indicated that the facility is required to send notice to the local LTC Ombudsman for any transfer or discharge initiated by the facility. The administrator acknowledged that the behavioral unit is licensed under the skilled nursing facility and is therefore required to follow state regulations, including ombudsman notification for all discharges and transfers. No evidence was found in the health records that the ombudsman had been notified for any of the affected residents.
Plan Of Correction
On 4/26/25, the Administrator reviewed the content of AFL 17-27 with the Social Services Director (SSD) and Behavioral Unit's Program Director (PD) and Nurse Manager (NM) for compliance. The Administrator stressed AB 940's requirement that the facility 1) must notify the local LTC Ombudsman at the same time notice is provided to the resident or resident's representative when a facility-initiated transfer or discharge occurs, and 2) is required to provide a copy of the notice to the LTC Ombudsman as soon as practicable if the resident is subject to a facility-initiated transfer to a general acute care hospital on an emergency basis. The SSD will maintain a binder organized by year containing 1) a list of all discharged residents to date, 2) copies of the facility-initiated transfer notices, and 3) proof of transmission of the notices to the LTC Ombudsman's office. The PD and NM will maintain the same for the Behavioral Health Unit. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.