Failure to Notify Ombudsman of Resident Discharge and Hospital Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of a resident's discharge and transfers to the hospital. The resident, who had multiple complex medical conditions including a left lower leg fracture, atrial fibrillation, end-stage renal disease requiring dialysis, diabetes mellitus, congestive heart failure, and deep vein thrombosis, was hospitalized twice for fluid overload and thrombosis. Documentation in the electronic medical record confirmed these hospitalizations, but there was no evidence that the LTCO was notified of either discharge or transfer. Interviews with facility staff, including an administrative nurse and social services staff, revealed that they were unaware of the requirement to notify the ombudsman of such discharges. The facility's own Discharge and Transfer policy stated that a notice of transfer must be provided to the resident, their representative, and the ombudsman as soon as practicable in the event of an emergency transfer. Despite this policy, the required notifications were not made.