Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman upon the transfer of multiple residents to the hospital. Clinical record reviews for several residents revealed that, following changes in their conditions, they were transferred and admitted to the hospital. However, there was no documentation that the required written notification was provided to the State Ombudsman regarding these transfers. This deficiency was identified for nine out of ten residents reviewed for hospitalizations. Specific examples include residents who were sent to the hospital due to chest pain, changes in condition, or for re-evaluation, with subsequent documentation confirming their admission to the hospital. Despite these transfers, the records lacked evidence that the Ombudsman was notified as required by federal regulations. Interviews with the Nursing Home Administrator confirmed that notifications to the Ombudsman were not being sent for hospital admissions. The surveyor reviewed these findings with the Nursing Home Administrator, who acknowledged that the facility did not send notifications for hospital admissions. The lack of documentation and notification was consistent across multiple cases, indicating a systemic failure to comply with the regulatory requirement to inform the State Ombudsman of resident transfers to the hospital.
Plan Of Correction
1. The State Long Term Care Ombudsman will be notified via email of the transfers of Residents 13, 23, 26, 28, 50, 55, 57, 64, and 66. 2. NHA/designee will audit the facility-initiated transfers for the last 30 days to ensure that the Office of the State Long-Term Care Ombudsman was notified. 3. Social Service Director/designee will maintain a log of residents transferred from the facility. Monthly, the NHA/designee will audit the log to ensure compliance, and SSD will submit the log to the Office of the State Long-Term Care Ombudsman. The date of notification will be recorded on the audit form. 4. All hospital transfers will be reviewed in AM meeting 4x a week for 4 weeks, and weekly x2 months to ensure written notification was provided to the State Long Term Care Ombudsman. Results of the audits will be presented at the Quality Assurance Performance Improvement meetings for review and to ensure ongoing compliance.