Failure to Notify Ombudsman of Resident Transfers to Hospital
Penalty
Summary
The facility failed to provide written notice of transfer to the Long-Term Care Ombudsman for two residents who were transferred to the hospital. Interviews with staff, including the Director of Staff Development, Administrator, Licensed Nurses, and Social Services Director, revealed that none were aware of the requirement to notify the Ombudsman when residents were transferred to the hospital. Staff members confirmed that they had not completed notices of transfer nor notified the Ombudsman in such cases. The Director of Nursing verified that no notice was completed and the Ombudsman was not notified for the two residents transferred to the hospital at the end of March 2025. A review of the facility's policy and procedure indicated that the Ombudsman should be notified in all cases of transfer or discharge, in accordance with regulatory requirements. Additionally, an All Facilities Letter specified that notice must be sent to the local LTC Ombudsman for any transfer or discharge initiated by the facility. Despite these requirements, the facility did not notify the Ombudsman for the two residents transferred to the hospital, as confirmed by staff interviews and record review.