Failure to Notify State LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that proper discharge notifications were completed for two residents who were transferred to the hospital. In both cases, documentation showed that the residents were sent to the emergency department or hospital, and all physician orders were discontinued for one of the residents. The State LTC Ombudsman reported not receiving any discharge notifications from the facility for several months. Interviews revealed that the social worker was not involved in notifying the ombudsman's office and had only recently received official training, while the nursing home administrator stated that the social worker was responsible for these notifications and that reports should be sent monthly. As a result, the required notifications to the State LTC Ombudsman regarding resident discharges were not completed.