Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of resident discharges as required, affecting three out of four residents reviewed for discharge. Medical record reviews for these residents showed that each had been admitted, discharged to the hospital, and in some cases readmitted, with diagnoses including chronic lymphocytic leukemia, chronic kidney disease, cirrhosis of the liver, diabetes mellitus type two, fibromyalgia, mood disorder, atrial fibrillation, congestive heart failure, pleural effusion, and Clostridium difficile infection. Despite these discharges, there was no documentation in the nursing progress notes indicating that the Ombudsman had been notified of the residents' discharges to the hospital. Interviews with facility staff confirmed the lack of notification. The DON acknowledged that the facility had not been notifying the Ombudsman of discharges, and the Social Services Director, who was new to the position, was unaware of the requirement until recently. Review of the facility's Bed Hold and Return to Center policy referenced a Notice of Transfer Discharge policy, but this policy was not provided for review. The deficiency was identified during an investigation under a specific complaint number.