Failure to Timely Notify Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The facility failed to provide the required proposed transfer and discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman at the same time the notice was given to the resident and/or their representative for two sampled residents. For one resident with a history of pelvic fracture who was being discharged to board and care on hospice, the notice was signed by the resident and given to the family member, but the Ombudsman was not notified until the following day. Similarly, for another resident with coronary artery disease and a history of coronary artery bypass grafting, the discharge notice was provided to the resident's representative, but the Ombudsman received the notice a day later. Interviews and record reviews confirmed that the facility's Director of Social Services typically sent the notice to the Ombudsman on the day of discharge, rather than concurrently with the notice to the resident or representative. The facility's policy requires that the Ombudsman be notified at the same time as the resident and representative. This lapse resulted in the Ombudsman not being informed in a timely manner, as required by policy and regulation.