Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state-appointed ombudsman of a resident's discharge, as required by both facility policy and regulatory standards. According to the facility's Discharge Planning Process policy, notification to the ombudsman should occur by fax on the date of discharge. Record review showed that a resident was admitted and later discharged, but there was no documentation of ombudsman notification for this discharge. The facility's Record of Transfers/Discharges also did not contain evidence of such notification for the resident in question. Interviews with facility staff revealed confusion regarding responsibility for ombudsman notifications. The Social Services Director was initially unsure who was responsible, later indicating that the DON handled notifications. The DON confirmed that the facility only notifies the ombudsman for hospital transfers, not for discharges, and acknowledged that no notification was made for this resident's discharge. This lack of notification was confirmed through both documentation review and staff interviews.