Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO) regarding the hospital transfers of two residents, resulting in a deficiency related to required documentation and notification. For one resident with a history of Alzheimer's disease, hypertension, diabetes, and a recent femur fracture, the clinical record did not show evidence that the Ombudsman was notified when the resident was transferred to the hospital for treatment. The resident's care plan and progress notes documented the transfer and subsequent readmission, but the omission of notification was confirmed by facility staff, who stated the resident was mistakenly missed during the notification process. Another resident, also with Alzheimer's disease and additional diagnoses including chronic kidney disease and encephalopathy, was transferred to the hospital following a decline in condition, including confusion, weakness, and respiratory symptoms. The resident's niece was notified of the transfer, and the resident was later readmitted to the facility. However, the clinical record lacked documentation that the LTCO was notified of the discharge to the hospital. Facility staff confirmed that this resident was not included in the monthly report sent to the Ombudsman office, as required by facility policy. Facility policy states that residents or their representatives must be notified in writing of impending transfers or discharges, and a copy of this notice must be sent to the Office of the State Long-Term Care Ombudsman at the same time. In both cases, the required notification to the Ombudsman was not completed, as confirmed by staff interviews and review of the clinical records.