Failure to Notify Ombudsman and Provide Written Discharge Notices
Penalty
Summary
The facility failed to provide required written notification of discharge and the reasons for transfer in a language and manner understandable to the resident, and did not send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for two residents. For one resident with diagnoses including type 1 diabetes mellitus and end-stage renal disease, multiple hospital transfers were documented in the medical record. However, the Admissions Marketing Director (AMD) stated that the Ombudsman was only notified monthly of residents discharged against medical advice (AMA) or to the community, and not when residents were transferred to a hospital. The Regional Nurse Consultant (RNC) confirmed that the Ombudsman should be notified of all discharges, including hospital transfers, but this was not done for this resident. Another resident with a history of paranoid schizophrenia, major depressive disorder, and other medical conditions left the facility with a friend and did not return. The resident later came back to collect belongings and stated he would not return. The Administrator acknowledged that no AMA form or discharge instructions were provided because the resident was in a rush, and the Ombudsman was not notified of the resident's departure. The AMD considered the situation as leaving AMA, but did not follow the required notification procedures. Interviews with facility staff, including the Administrator, AMD, RNC, and Director of Nursing (DON), revealed inconsistent practices regarding notification of the Ombudsman and provision of discharge documentation. Staff described procedures for contacting residents or families and involving law enforcement if a resident did not return from a leave of absence, but did not consistently notify the Ombudsman or provide written discharge notices as required.