Failure to Notify Ombudsman and Issue Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide required notifications and documentation related to resident transfers and hospitalizations for three residents. For two residents with complex medical conditions, including acute kidney failure, multiple sclerosis, diabetes mellitus, general anxiety disorder, and acute respiratory failure, there was no documented evidence that the Ombudsman was notified of their transfers to the hospital, as required. This was confirmed through both record review and staff interview, which revealed that the Social Service Designee did not notify the Ombudsman of these hospitalizations. Additionally, for a third resident with diagnoses such as cerebral infarction, pneumonia, hemiplegia, sepsis, gastrostomy status, and dementia, there were no transfer notices issued for two separate hospitalizations. The resident was noted to have severely impaired cognition and required maximum assistance with daily activities. The absence of required transfer notices was verified by the Corporate Director of Operations. These deficiencies affected all three residents reviewed for hospitalization.