Failure to Notify 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 two residents who were discharged, one to a hospital and one to home with family. Record reviews showed that neither resident's electronic medical record contained evidence that the Ombudsman was notified prior to their discharge, as required by facility policy. Both residents had intact cognition as indicated by their BIMS scores, and their medical histories included conditions such as acute respiratory failure, COPD, hypertension, diabetes, and dementia. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the Ombudsman of resident discharges. The Social Services Director stated she was unaware of the need to notify the Ombudsman and had not done so for any discharges during her tenure. The state LTC Ombudsman representative confirmed that no discharge notices had been received from the facility in the past year. The facility's policy specifies that a copy of the discharge notice must be sent to the Ombudsman, but this was not followed in these cases.