Failure to Notify State Ombudsman and Provide Contact Information During Resident Transfers
Penalty
Summary
The facility failed to notify the State Ombudsman Office when residents were transferred to the hospital or discharged, and did not provide residents with the required contact information for the State Ombudsman Office. This deficiency was identified for three sampled residents who experienced transfers or discharges, as their transfer/bed hold notices lacked the necessary ombudsman contact details. Staff interviews revealed a lack of awareness regarding the requirement to notify the ombudsman and to include their contact information on transfer/discharge forms. Additionally, the facility was unable to provide documentation showing that the ombudsman had been notified of these transfers or discharges. Facility policy indicated that notice of transfer or discharge should be provided to the resident, their representative, and the LTC ombudsman when practicable. However, review of the records for the affected residents showed that this policy was not followed, as the required notifications and contact information were missing. Staff confirmed that notification to the ombudsman was only done in specific circumstances, such as incident reports, and not routinely for all transfers or discharges.