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F0628
D

Failure to Notify Ombudsman of Emergency Transfers

Philadelphia, Pennsylvania Survey Completed on 06-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding facility-initiated emergency transfers to the hospital for three residents. For one resident, clinical records showed increased abdominal girth and no bowel movement for three days, resulting in a physician-ordered hospital transfer. Another resident had abnormal laboratory results and was also transferred to a hospital for evaluation per physician orders. A third resident experienced an unwitnessed fall, sustained a hematoma to the head, and was subsequently transferred to the hospital. Review of documentation and staff interviews confirmed that the required notification to the Ombudsman was not made for these emergency transfers.

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