Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman's office of a resident's discharge, as required by regulation. Specifically, a resident with diagnoses including rheumatoid arthritis, anemia, and type 2 diabetes mellitus was discharged home with medications and home care services in place. Although the discharge paperwork was reviewed and signed with the resident, a review of the facility's records and the Ombudsman's office reports revealed that the required notification of this discharge was not sent. Further review of transfer notices from January to June showed that no routine discharges were reported to the Ombudsman's office during this period, only hospitalizations. Interviews with facility staff revealed a lack of awareness regarding the requirement to report all discharges and transfers to the Ombudsman's office. The Director of Admissions, responsible for sending these notifications, stated she had only been reporting hospitalizations and involuntary discharges, not routine discharges, and was unaware of the broader reporting requirement. The Administrator also confirmed that the facility did not have a policy for reporting all transfers and discharges, and had only been following the practice of reporting hospitalizations and involuntary discharges.