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F0628
D

Failure to Notify Ombudsman of Resident Hospital Transfer

Bakersfield, California Survey Completed on 06-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the Ombudsman of a resident's transfer to the hospital on two separate occasions, as required by facility policy. During an interview and record review with the DON, it was confirmed that there was no fax confirmation or other documentation to show that the Ombudsman had been notified when the resident was transferred to an acute care facility. The facility's policy states that notification to the Ombudsman must occur as soon as practicable for facility-initiated discharges, including temporary transfers to hospitals. This lack of documentation and notification was identified through review of the resident's discharge summaries and facility procedures.

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