Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide copies of written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for eight out of nine residents who were transferred out of the facility. Clinical record reviews showed that multiple residents were transferred to the hospital following changes in their conditions, but there was no documented evidence that the required notifications were sent to the Ombudsman. This deficiency was identified for residents who experienced transfers on various dates, with some residents being transferred more than once without the appropriate notifications being documented. During an interview, the Director of Nursing confirmed that the written discharge or transfer notices were not sent to the Office of the State Long Term Care Ombudsman as required. The lack of documentation and notification was consistent across all identified cases, indicating a systemic failure to comply with the notification requirements outlined in 28 Pa. Code 201.14(a).