Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of transfers and discharges for one resident who was hospitalized on two separate occasions. The resident, who had moderate cognitive impairment and required assistance with all activities of daily living, had multiple diagnoses including atrial fibrillation, heart failure, hypertension, cerebrovascular accident, depression, ADHD, and aortic aneurysm and dissection. Medical records showed that the resident was discharged to the hospital with return anticipated on two occasions, and hospital discharge summaries indicated hospitalizations for acute metabolic encephalopathy and acute on chronic hypoxemic hypercapnic respiratory failure. Review of the facility's monthly notices to the Ombudsman for the relevant months did not include this resident's transfers or discharges. During an interview, the social service assistant confirmed that the resident's hospitalizations were not reported to the Ombudsman as required. No policy regarding the notification process was provided by the facility during the survey.