Failure to Notify Ombudsman and Document Resident Discharge Process
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident's representative to ensure a safe and orderly transfer or discharge. Specifically, the facility did not notify the resident's representative, which in this case was the Office of the State Long-Term Care Ombudsman, of the transfer or discharge in writing, nor did they provide the reasons for the move in a language and manner that could be understood. Additionally, a copy of the notice of transfer or discharge was not sent to the Ombudsman representative as required by facility policy. Interviews with facility staff revealed that the responsibility for beneficiary notices was assigned to the business office manager and social worker, but the Ombudsman was not notified. The social worker also stated that she only worked with skilled residents and not long-term residents. The resident involved had a history of joint replacement surgery, diffuse traumatic brain injury, unspecified convulsions, and hallucinations. The resident was discharged to a private home with home health services after a 39-day stay. Documentation showed that the resident was picked up by their representative and referred to home health for continued physical therapy, with follow-up appointments scheduled with their primary care provider. However, the required notifications to the Ombudsman and proper documentation of the discharge process were not completed, as confirmed by record review and staff interviews.