Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for one of four residents reviewed for admission, transfer, and discharge requirements. Specifically, a resident was admitted to the facility and later transferred to a local hospital emergency room, then returned to the facility. There was no documentation of this transfer in the facility's Ombudsman Emergency Transfer Log or the Census Change Sheet for the relevant month. Interviews with facility staff revealed that the staff member responsible for updating the Emergency Transfer Log did not receive notification of the transfer because the assigned nurse did not complete the Census Change Sheet at the time of the resident's transfer. The assigned nurse confirmed she did not fill out the required documentation and was unaware of the requirement to do so. Facility leadership confirmed that the transfer was not documented as required and that the process for ensuring accurate notification to the Ombudsman was not followed.