Failure to Notify Ombudsman of Resident Discharges and 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 four residents who were transferred or discharged. Clinical record reviews showed that one resident was transferred to the hospital on two separate occasions following significant changes in condition, and another resident was also transferred to the hospital twice after similar changes. Two additional residents were either transferred to the hospital or discharged home, but in all cases, there was no documented evidence that the required notifications were sent to the Ombudsman. During an interview, the Director of Nursing confirmed that the written discharge or transfer notices were not sent to the Ombudsman as required. This deficiency was identified through both clinical record review and staff interview, and it was cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.