Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the discharge of two residents. For the first resident, who had diagnoses including acute and chronic respiratory failure with hypercapnia and chronic obstructive pulmonary disease, the medical record showed an admission and subsequent discharge after transfer to the hospital. There was no documentation in the medical record indicating that the Ombudsman was notified of this discharge, and the Administrator confirmed that the notification did not occur. For the second resident, who had diagnoses of hepatic encephalopathy, low back pain, alcoholic cirrhosis, and chronic viral hepatitis C, the medical record indicated that the resident left the facility against medical advice. The Minimum Data Set assessment showed the resident was cognitively independent. Again, there was no evidence in the medical record that the Ombudsman was notified of this discharge, and the Administrator verified the lack of notification. The facility's own policy required notification to the Ombudsman as soon as practicable, but this was not followed in these cases.