Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide required notification to the Office of the State Long-Term Care Ombudsman regarding resident transfers to the hospital for five out of eleven residents reviewed. Clinical record reviews and facility documentation revealed that notifications were not sent for multiple hospitalizations involving residents with diagnoses such as muscle weakness, unsteadiness, hypertension, diabetes, hemophilia, neuromuscular dysfunction of the bladder, dementia, chronic kidney disease, depression, and chronic pain syndrome. Specific instances included residents being transferred to the hospital on several occasions, with no evidence that the Ombudsman was notified as required by regulation. Staff interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that they expected all resident transfers to be reported to the Ombudsman in a timely manner, but documentation and email communications indicated that notifications were not made at the time of the transfers. The deficiency was identified through review of clinical records, facility documentation, and staff interviews, which consistently failed to show timely notification to the Ombudsman for the affected residents' hospitalizations.