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F0628
D

Failure to Notify Ombudsman of Resident Discharge

Holdrege, Nebraska Survey Completed on 08-05-2025

Penalty

18 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the state Long Term Care Ombudsman of a resident's discharge, as required by both facility policy and regulatory requirements. Record review showed that a resident was admitted and subsequently discharged, but there was no documentation in the medical record indicating that a discharge notice was provided to the ombudsman. The facility's policy specifies that a copy of all discharge notices must be sent to the ombudsman and relevant state agencies, with documentation of the date this was completed in the resident's record. Interviews with the Social Services Director (SSD) revealed that the SSD was unaware of the requirement to notify the ombudsman of resident discharges, and only notified the ombudsman of hospital transfers. Review of the facility's monthly notification email and the Emergency Transfers From Facility form confirmed that the resident's discharge was not included in the ombudsman notification. The SSD confirmed that the omission was due to a lack of awareness of the requirement.

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