Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide routine written notifications of resident transfers and discharges, including required information to the local Ombudsman, for four of twelve sampled residents. Specifically, documentation showed that several residents were transferred to hospitals or discharged due to death, but the required notices were not sent to the Ombudsman as mandated. Interviews revealed that the staff member responsible for sending these notifications did not consistently provide them, either by email or mail, and did not maintain copies of the notices. The Social Services Director or designee was expected to send these notifications, but this process was not followed for several months. Facility policy required that notices of transfer or discharge, including emergency transfers, be sent to the Ombudsman as soon as practicable and that evidence of such notifications be maintained. However, the Ombudsman reported not receiving these notices for months, and the staff member acknowledged not having sent or retained copies of the required documentation. A retrospective list of transfers and discharges was eventually provided, but it did not demonstrate timely or routine notification as required by policy.