Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman regarding hospital transfers for two residents who were reviewed. Both residents had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores of 14 and had multiple chronic medical conditions, including heart failure, hypertension, coronary artery disease, chronic kidney disease, respiratory failure, diabetes, anxiety, and depression. Documentation review showed that these residents experienced multiple hospital admissions and readmissions over several months. However, their names were not included on the facility's Notice of Transfer Form to the Ombudsman for the relevant months in which the transfers occurred. Interviews and policy review revealed that the Social Worker, who was responsible for Ombudsman notifications, misunderstood the reporting requirements. The Social Worker only reported residents who did not want a bed hold, omitting those who had or wanted a bed hold from the Ombudsman report. This practice was inconsistent with the facility's policy, which required all discharges and types of discharges to be reported to the Ombudsman office as requested.