Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman of two residents' transfers to the hospital, as required by facility policy. One resident with severely impaired cognition and multiple diagnoses, including coronary artery disease and non-Alzheimer's dementia, was admitted to the hospital for pneumonia and RSV. Another resident with moderately impaired cognition and diagnoses such as diabetes mellitus and a right artificial hip joint was hospitalized due to a right hip fracture. Review of the facility's tracking forms for Ombudsman notification showed that neither resident was listed for the relevant months in which their hospitalizations occurred. During staff interview, the Administrator stated she was responsible for Ombudsman notifications but was unaware that hospitalizations required reporting, believing only discharges to home or another facility needed to be reported. The facility's policy, however, specified that all transfers and discharges, including those to hospitals, must be reported to the Ombudsman. This discrepancy between policy and practice led to the deficiency.