Failure to Notify Ombudsman of Resident Hospital Transfers and Discharges
Penalty
Summary
The facility failed to provide written notification to the Ombudsman regarding a resident's transfer and discharge to the hospital. Record review showed that a resident was admitted to the facility and subsequently transferred to the hospital on two separate occasions for further medical evaluation and treatment, including lack of appetite, generalized weakness, and urinary retention. The resident was readmitted to the facility after each hospital stay. Despite these transfers and discharges, there was no documentation that the Ombudsman was notified in writing as required. Interviews with facility staff revealed a lack of awareness and implementation of the requirement to notify the Ombudsman. The Ombudsman confirmed she did not receive a hospital transfer and discharge list for the relevant month. The DON indicated that social work was responsible for this communication, but the assigned social worker was unaware of the requirement and had not sent any such notifications since starting employment. The Administrator also confirmed that the process had not been followed, as no one at the facility was currently sending the required information to the Ombudsman.