Failure to Notify LTC Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman regarding a resident who was transferred to the hospital on multiple occasions. Clinical record review and staff interviews confirmed that the required notification was not completed for this resident, who had diagnoses including quadriplegia, anxiety, depression, and chronic pain, and was assessed as having no cognitive impairment. Documentation showed the resident was transferred to the hospital three times and subsequently readmitted to the facility each time, with corresponding entries in the progress notes, census records, and MDS assessments. Despite these transfers, review of the facility's Notice of Transfer Forms for the relevant months did not include the resident's name, indicating the ombudsman was not notified as required. Interviews with facility staff, including the Nurse Consultant and Administrator, confirmed the omission, with the Administrator noting that the resident's name did not appear on the electronic report used for notifications. This failure to notify the ombudsman represents a deficiency in meeting regulatory requirements for resident transfers.