Failure to Notify Ombudsman of Resident Hospital Discharge
Penalty
Summary
Facility staff failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding the hospital discharge of a resident. The deficiency was identified through resident record review, staff interviews, and examination of facility documents. The resident involved had a history of atherosclerosis, diabetes, and chronic kidney disease, and had recently undergone a right above the knee amputation. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), and required varying levels of assistance with self-care activities as documented in the Minimum Data Set (MDS) assessment. Nursing notes indicated the resident was admitted to the hospital following a vascular appointment and was expected to remain hospitalized for at least a week. Despite this, there was no documentation that the Ombudsman was notified of the resident's discharge to the hospital. The Social Services Director confirmed the lack of notification and was initially unaware that this responsibility fell under her role at the facility. During a final interview, facility leadership did not provide additional comments or concerns regarding the incident.