Failure to Notify Ombudsman and Provide Required Transfer Documentation
Penalty
Summary
Facility staff failed to provide required notifications and documentation related to resident transfers and discharges for three residents. In two cases, staff did not notify the local long-term care ombudsman of a resident's transfer or discharge. One resident, who was cognitively intact and discharged home with home health services after an insurance cut, had filed an appeal for discharge, but there was no evidence that the ombudsman was notified of the planned discharge. Another resident, also cognitively intact, was transferred to the hospital, and review of facility records confirmed that the ombudsman was not notified of this transfer/discharge. Additionally, for a third resident who was transferred to the hospital for acute symptoms including chest pain, shortness of breath, and dizziness, the facility failed to provide the receiving hospital with proper documentation at the time of transfer. This resident, who had mild cognitive impairment, was also not given information about the facility's bed hold policy prior to discharge. Interviews with facility staff and review of records confirmed that there was no evidence of the required documentation being provided to the hospital or the resident. Facility policies reviewed by surveyors indicated that staff were required to notify the ombudsman and provide proper documentation during transfers and discharges, but these procedures were not followed in the cases identified. The deficiencies were confirmed through staff interviews, clinical record reviews, and examination of facility documentation, with no further information provided by the facility prior to the survey exit.