Failure to Notify Ombudsman Prior to Resident Discharge
Penalty
Summary
The facility failed to provide a copy of the notice of transfer or discharge to the State Long-Term Care Ombudsman prior to the planned discharge for three sampled residents. For each resident, documentation showed that the resident and their representative were notified of the discharge, and the discharge was carried out as planned. However, there was no evidence in the records that the Ombudsman was notified prior to the discharge, as required by facility policy and federal regulations. Interviews with facility staff, including the Social Worker, Case Manager, and Assistant Administrator, confirmed that the process for notifying the Ombudsman was not followed, with explanations including uncertainty about the Ombudsman's coverage and issues with email communication. The residents involved had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction, metabolic encephalopathy, dementia, acute osteomyelitis, and dissection of the descending thoracic aorta. Despite the facility's policy requiring notification of the Ombudsman and documentation of such notification in the medical record, this step was omitted for all three residents prior to their discharge. The facility's own policies also require that residents and their representatives be informed of their right to appeal the discharge, including contact information for the Ombudsman, but the lack of Ombudsman notification was a clear deficiency in the discharge process.