Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to ensure that a copy of the notice of transfer or discharge was sent to the Ombudsman when a resident was transferred to the hospital. The resident, who had a history of cellulitis and chronic obstructive pulmonary disease (COPD), was sent to the hospital for a left 4th toe infection as per physician's orders. Upon review of the resident's clinical and hospitalization records, there was no documentation indicating that the required notice was sent to the Ombudsman. Interviews with facility staff, including the DON, Social Services, Medical Records, and the Administrator, revealed that the facility did not have a process, policy, or procedure in place for notifying the Ombudsman when residents are transferred to the hospital. Staff indicated that notifications to the Ombudsman were only made for planned discharges to home or other care settings, not for hospital transfers. This lack of notification was confirmed through record reviews and staff statements.