Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman when a resident was transferred to a general acute care hospital. The resident, who had a medical history including diabetes, hypertension, osteomyelitis of the right foot, and chronic kidney disease, was transferred to the hospital for gangrene of the right foot. Documentation reviewed included the resident's admission record, progress notes, and SBAR, all confirming the transfer and the medical reasons for it. However, there was no evidence in the records that the ombudsman was notified of this transfer. Interviews with the Social Worker, Director of Nursing (DON), and Administrator confirmed that the facility's process requires notification of the ombudsman for all transfers or discharges, and that this notification did not occur in this case. The facility's policy also specifies that notice should be given to the ombudsman as soon as practicable before a transfer. Both the Social Worker and DON acknowledged the omission, and the Administrator verified the lack of documentation regarding ombudsman notification for the resident's transfer.