Failure to Notify Ombudsman of Facility-Initiated Discharge
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of a facility-initiated discharge of a resident to the hospital. The resident in question had a history of chronic kidney disease with behavioral disturbance, osteoporosis, and encephalopathy, and was documented as having severe cognitive impairment, requiring extensive staff assistance with activities of daily living, and being frequently incontinent. On the day of the incident, the resident experienced a change in mental status, was unable to assist with transfers, and was observed by a speech therapist to be leaning to the left and drooling. The physician was notified and ordered the resident to be sent to the hospital for evaluation, with the resident's DPOA agreeing to the transfer. The resident was subsequently admitted to the hospital and later readmitted to the facility. Despite the facility's policy requiring notification of the LTCO for all facility-initiated discharges, there was no documentation in the clinical record that such notification was made for this resident's discharge. Administrative staff confirmed that they did not send notifications of discharge to the Ombudsman for long-term care residents, only for assisted living residents. The facility's policy also outlined specific documentation requirements for discharges, including the basis for transfer and communication with the Ombudsman, which were not followed in this case.