Failure to Notify State Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of a resident's discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman prior to the resident's discharge, as required. Record review and interviews confirmed that a resident with diagnoses including Guillain-Barre disease, respiratory failure, and a tracheostomy was admitted for LTC and later discharged to a hospital for elevated care, with no expectation of return. There was no evidence in the medical record that a discharge notice was sent to the state ombudsman. Interviews with the state ombudsman, social worker (SW), director of nursing (DON), and administrator revealed that none were aware of a notification being made to the ombudsman regarding the resident's discharge. The SW stated she had been directed not to coordinate with the ombudsman and had no evidence of a report for the discharge. The facility's policy indicated that for resident-initiated discharges, notification to the ombudsman was not required, but the discharge in question was not clearly documented as resident-initiated.