Failure to Notify Ombudsman of Facility-Initiated Hospital Discharge
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of a facility-initiated discharge of a resident to the hospital. The resident had multiple complex medical conditions, including atherosclerotic heart disease, cerebral infarction, diabetes mellitus, stage 3 renal failure, and hypocalcemia. The resident required extensive staff assistance with activities of daily living, was frequently incontinent, required continuous oxygen, and used a wheelchair. On two separate occasions, the resident experienced changes in condition that resulted in transfers to the hospital—first for hyperkalemia and later for congestive heart failure exacerbations. In both instances, the resident was admitted to the hospital and later returned to the facility. Review of the electronic medical record and staff interviews revealed that there was no documentation of notification to the LTCO regarding the resident's discharge to the hospital. The facility's social services staff confirmed that they do not notify the Ombudsman when a resident is discharged to the hospital, only when discharged home or to another facility. Additionally, the facility did not provide an Admission, Transfer, Discharge policy when requested.