Failure to Notify Ombudsman and Provide Required Transfer/Discharge Documentation
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers, discharges, and hospitalizations, specifically neglecting to notify the State Long Term Care Ombudsman and, in some cases, the residents or their representatives. In one instance, a resident was sent to the hospital after being found using illegal drugs and making threats to return with a gun and harm others. The facility did not provide a 30-day discharge notice at the time of the incident, and when a notice was eventually produced, there was no evidence it was delivered to the resident or sent to the Ombudsman as required. The Ombudsman confirmed that she did not receive the notice until months later, after repeated requests and only after the surveyor's intervention. Similar deficiencies were found in the cases of four other residents who were transferred to acute care facilities for various medical reasons, including abnormal vital signs, shortness of breath, and sepsis. In these cases, the facility either failed to provide timely notification to the Ombudsman or could not produce documentation verifying that such notification had occurred. In some instances, notices were only sent after the surveyor requested verification, and staff confirmed that the required notifications had not been completed at the time of transfer. The review of records, staff interviews, and communication with the State Long Term Care Ombudsman revealed a consistent pattern of noncompliance with federal requirements for notifying the Ombudsman and, when appropriate, the resident or their representative regarding transfers and discharges. This deficiency was identified in all five residents reviewed for discharge and hospitalization during the survey, indicating a systemic issue with the facility's notification and documentation processes.