Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers and discharges for two residents out of a sample of twelve. Specifically, one resident with moderate cognitive impairment and an activated Power of Attorney for Health Care was transferred to the hospital due to urinary retention and constipation, but the Ombudsman was not notified of this transfer. Documentation showed that a notice of bed hold and reason for transfer was signed by the POAHC, but the required Ombudsman notification was not completed. Another resident, who had diagnoses including cerebral infarction, chronic headaches, dizziness, and chronic kidney disease, was discharged to an assisted living home without the Ombudsman being notified. Review of the facility's records revealed that the list provided to the Ombudsman only included residents who were readmitted from the hospital and did not account for those who were transferred, discharged, or had passed away. The Nursing Home Administrator confirmed that the Social Worker was responsible for notifications but only sent information about hospital readmissions.