Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the Ombudsman regarding the transfer of two residents to the hospital. For one resident, there were three separate hospital transfers for conditions including chest pain, difficulty breathing, altered mental status, low blood pressure, and shortness of breath. In each instance, the medical record documented the resident's discharge and subsequent return to the facility, but there was no documentation that the Ombudsman had been notified of these transfers. Attempts to locate the previous Social Worker's documentation or to interview her were unsuccessful, and the Administrator reported being unable to find any records of Ombudsman notification, suggesting that documentation may have been removed when the previous Social Worker left the facility. For the second resident, a transfer to the hospital occurred for further evaluation of abnormal laboratory results. The Social Worker interviewed stated she typically emailed the list of transfers to the Ombudsman but could not find any record of notification for this particular transfer. The Administrator confirmed that no documentation could be found to show that the Ombudsman had been notified. The Social Worker acknowledged that the notification may have been overlooked during the relevant period.