Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide the required written notice of discharge to the State Long-Term Care Ombudsman's office for two residents who were being discharged. Both residents received a Notice of Discharge with an effective discharge date, but there was no documentation that a copy of this notice was sent to the Ombudsman as required. Interviews with the Business Office Manager, Director of Nursing, and Administrator confirmed that the Ombudsman was not notified, and the Ombudsman’s office also confirmed they did not receive the required notifications. The facility’s own policy and procedure stated that a copy of the discharge notice must be sent to the Ombudsman at the same time it is provided to the resident and their representative, but this was not followed. Resident 1 had a history of necrotizing fasciitis and a below-knee amputation, while Resident 2 had type 2 diabetes with diabetic neuropathy and cellulitis of the left lower limb. Both residents confirmed receipt of their discharge notices. The failure to notify the Ombudsman removed the opportunity for advocacy on behalf of the residents regarding their discharge decisions.