Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
A deficiency was identified when the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for one resident. The resident, who had been admitted with diagnoses including aftercare following joint replacement surgery and the presence of a right artificial knee joint, was discharged against medical advice (AMA) to home. Documentation in the nurse's note confirmed the discharge event. Interviews with facility staff revealed a lack of consistent practice and training regarding notification of the Ombudsman. The Resident Advocate (RA) and Business Office Manager (BOM) both stated that they did not notify the Ombudsman for every discharge, only in cases they considered difficult or when there were concerns for the resident's safety. The Director of Nursing (DON) was unaware that all discharges required notification, and the Regional Nurse Consultant (RNC) clarified that notification should occur for every discharge, typically via a monthly summary. This inconsistency led to the failure to notify the Ombudsman about the resident's discharge.