Failure to Notify LTCO of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the state Long Term Care Ombudsman’s (LTCO) office regarding the transfer or discharge of two residents who were hospitalized and subsequently discharged. For one resident admitted with aftercare following surgery and cellulitis, documentation showed a transfer to the hospital for nausea and vomiting, but there was no record of LTCO notification. For another resident with Alzheimer’s Disease and metabolic encephalopathy, records indicated a hospital transfer due to wound complications and subsequent discharge from the facility, again without any evidence of LTCO notification. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Administrator, revealed that both were unaware of the requirement to notify the LTCO’s office for resident transfers and discharges. The lack of notification was confirmed through both record review and staff statements, indicating a systemic failure to ensure required notifications were made for residents experiencing significant changes in their care setting.