Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the state Ombudsman of the discharge or transfer of two residents, as required by facility policy. One resident with severe cognitive impairment was admitted with the goal of discharging to the community and was later discharged accompanied by family, but there was no documentation in the electronic medical record (EMR) that the Ombudsman was notified of this discharge. Social Services staff confirmed that the Ombudsman had not been notified as required. The facility's policy states that the Ombudsman, along with the resident and their representative, must be notified of emergency transfers or discharges. Another resident with a diagnosis of congestive heart failure and moderately impaired cognition was discharged to a critical access hospital. The EMR for this resident also lacked documentation of Ombudsman notification regarding the discharge. Upon request, the facility was unable to provide evidence that the Ombudsman had been notified for either resident. The deficiency was identified through interviews and record reviews, which confirmed the lack of required notifications.