Failure to Notify State LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide required discharge notifications to the Office of the State Long-Term Care (LTC) Ombudsman for four residents who were either discharged to the hospital, discharged home, or issued 30-day discharge notices. In each case, record reviews revealed no evidence that the Ombudsman was notified prior to the residents' discharge or intended discharge. This included residents with significant medical needs, such as end stage renal disease requiring hemodialysis, severe cognitive impairment, and dependence on mechanical assistance for transfers and supplemental oxygen. Interviews with residents and their representatives indicated a lack of awareness regarding their rights and the services available through the LTC Ombudsman. One resident expressed anxiety about being discharged with nowhere to go and was unaware of the Ombudsman’s role until after receiving a discharge notice. Another resident’s family member reported not being informed about appeal options or alternatives to discharge, despite the resident’s high level of care needs and the family’s inability to provide appropriate care at home. Staff interviews revealed that both the Business Office Manager (BOM) and the Director of Nursing (DON) were unaware of the requirement to notify the Ombudsman of resident discharges. The BOM stated she had not been trained to keep evidence of mailing discharge notices and had not notified the Ombudsman of any discharges. The DON confirmed that the facility did not have a system in place to ensure Ombudsman notification. The facility’s policy did state that a copy of the discharge notice should be sent to the Ombudsman, but this was not being followed in practice.