Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of transfers or discharges for four residents, as required by policy and regulation. Specifically, one resident with multiple medical conditions and intact cognition was transferred to the hospital for evaluation, but the Ombudsman was not notified. Another resident with moderately impaired cognition and an activated Power of Attorney for Healthcare was discharged home, yet the required notification was not made. A third resident, who had intact cognition and multiple chronic conditions, was transferred to the hospital for a change in condition and later returned, but again, no notification was sent. The fourth resident, also with intact cognition and significant medical diagnoses, was transferred to the hospital on three separate occasions for serious health issues, including septic shock and urosepsis, without Ombudsman notification each time. The facility's policy mandates that the Social Services Director or designee must notify the Ombudsman of non-emergency transfers or discharges at least 30 days in advance, and for emergency transfers, provide notice via a monthly list. However, record review and staff interviews revealed that the facility did not report any transfers or discharges to the Ombudsman during the period in question. This deficiency was confirmed when the Nursing Home Administrator acknowledged the lack of reporting and provided documentation showing that no notifications had been made.