Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for two out of three sampled residents. According to the facility's policy and procedure on transfer and discharge, a written notice of discharge must be provided to the resident and a copy sent to the Ombudsman. However, record review and staff interviews confirmed that this notification was not completed for residents who were transferred to the hospital or who left against medical advice (AMA). Specifically, one resident with type 2 diabetes mellitus and diabetic chronic kidney disease was transferred to the hospital and discharged, while another resident with chronic obstructive pulmonary disease left the facility AMA and was discharged. The case manager and the director of nursing both confirmed that the required notifications to the Ombudsman office were not sent for these discharges.