Failure to Notify Ombudsman of Resident Hospital Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO) regarding the discharge or hospital transfer of several residents, as required by both federal regulations and the facility's own Admission, Transfer, and Discharge policy. The policy specified that a list of residents who had an emergency transfer and/or discharge would be sent to the LTCO monthly. However, documentation and staff interviews revealed that this notification was not consistently completed for residents who were transferred to the hospital but remained on bed hold or returned within the bed hold period. One resident with diagnoses including diabetes mellitus, major depressive disorder, and muscle weakness was transferred to the hospital for evaluation of increased pain, swelling, and an open area on the foot. The clinical record showed that while emergency services and the responsible party were notified, there was no documentation that the LTCO was informed of the discharge. Similar deficiencies were found for other residents with complex medical conditions, such as rhabdomyolysis, lactic acidosis, acute respiratory failure, and chronic respiratory failure, who were also transferred to the hospital. In each case, the facility's records lacked evidence of LTCO notification at the time of transfer or discharge. Interviews with administrative and social services staff confirmed that the facility's reporting system did not capture residents who were transferred to the hospital and remained on bed hold, unless they did not return within the 10-day period. As a result, the LTCO was not notified of these residents' transfers or discharges, contrary to the facility's policy. This failure was observed in multiple cases reviewed during the survey, indicating a pattern of non-compliance with required notification procedures.