Failure to Notify State LTC Ombudsman of Resident Discharges and Transfers
Penalty
Summary
The facility failed to ensure that copies of residents' discharge or transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman, as required by facility policy. This deficiency was identified through interviews, policy review, and record review, and was found to affect three residents who experienced transfers or discharges. Specifically, one resident with a sacrum fracture and diabetes was transferred to the emergency department, another resident with hemiplegia and heart disease was transferred to the emergency department and did not return, and a third resident with heart disease and diabetes was discharged to an assisted living facility. In each case, there was no documentation that the required notice was provided to the State Ombudsman. Further investigation revealed that the facility's policy, last revised in April 2025, required that copies of discharge or transfer notices be sent to the Ombudsman, with notices to be sent monthly. However, the Region 6 State Ombudsman confirmed that no such notices were received for several months in 2025. The Director of Clinical Services stated that the facility's Social Worker had left in March 2025, and as a result, the required notices were not sent during March, April, May, and part of June 2025.