Failure to Notify Ombudsman of Facility-Initiated Transfers
Penalty
Summary
The facility failed to provide copies of written notices regarding facility-initiated hospital transfers to the representative of the Office of the State Long-Term Care Ombudsman for five residents. Clinical record reviews showed that these residents were transferred to the hospital on various dates and subsequently readmitted to the facility. While written notices of the transfers were given to the residents and their representatives, there was no documented evidence that the required notifications were sent to the Ombudsman representative as mandated. An interview with the nursing home administrator confirmed that there was no documentation showing that copies of the transfer notices were sent to the Ombudsman for the identified residents. Furthermore, the administrator acknowledged that this failure to notify the Ombudsman representative was not limited to these cases but was a consistent issue for resident transfers from July 2024 through May 2025.