Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure that discharge notifications were made to the representative of the Office of the State Long-Term Care Ombudsman for one of seven reviewed residents. Specifically, a resident who was admitted with a lower right femur fracture and had intact cognition, as indicated by a BIMS score of 15, was discharged against medical advice (AMA). Documentation showed that the resident signed an AMA form after being informed of the risks and verbalizing understanding. However, a review of the facility's email notifications to the Ombudsman for the relevant month did not include this resident's discharge. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that it was the facility's policy and expectation to notify the Ombudsman of all discharges, including those occurring AMA, through a monthly report. The Social Services Director acknowledged that the resident's discharge should have been included in the report but was omitted. Facility policy also required that a copy of all discharge notices, including AMA discharges, be sent to the Ombudsman as soon as practicable, which did not occur in this instance.