Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide timely notification to the State Long-Term Care Ombudsman regarding the transfer and discharge of three residents. Interviews revealed that the ombudsman had not received any transfer or discharge notifications from the facility, despite having previously requested such notifications. Staff responsible for the notifications was unaware of the requirement and had not been sending the necessary information to the ombudsman. Record reviews confirmed that the medical charts for the affected residents did not contain evidence that the required notifications had been made at the time of their transfer or discharge. Specifically, one resident was transported to the Emergency Department, admitted to the hospital, and later returned to the facility, but there was no documentation of ombudsman notification. Two other residents were discharged from the facility, and their charts also lacked evidence of notification to the ombudsman. The deficiency was identified through interviews with staff and the ombudsman, as well as a review of resident records and facility correspondence.