Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that required transfer and discharge notifications were made to the Office of the State Long-Term Care Ombudsman for three residents who were discharged, including those who left against medical advice (AMA). Closed record review and staff interviews revealed that, although the facility's policy required notification of the Ombudsman for all resident discharges, there was no documentation that such notifications occurred for these cases. The residents involved had significant medical needs, including severe cognitive impairment, recent orthopedic surgeries, and conditions such as hemiplegia, acute kidney failure, and mobility issues. In each case, the discharge process was documented in the residents' records, including AMA forms and progress notes, but the required notification to the Ombudsman was not completed. Interviews with facility administration confirmed that social services staff, who were responsible for Ombudsman notifications, had left their positions without notice, resulting in administrative staff dividing these responsibilities. Despite this, the administrator acknowledged that there was no documentation to show that the Ombudsman had been notified of the AMA discharges. Facility policy review further confirmed the requirement for such notifications, but the lack of compliance was evident in the records reviewed.