Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of the discharge of two residents who were transferred to an acute care hospital. Review of facility policy indicated that written notice of transfer or discharge should include the name, address, and telephone number of the State Ombudsman, but the policy did not specify that the Ombudsman must be notified of the transfer or discharge itself. Record review showed that one resident was initially admitted with a need for care that could not be provided by the facility, and another resident had a primary diagnosis of chronic respiratory failure and also required care beyond the facility's capabilities. Notices of transfer or discharge were completed for both residents. Interviews with facility staff revealed that the process for notifying the Ombudsman involved the Social Worker running a monthly report of all transfers and discharges and sending notifications to the Ombudsman's office. However, the Ombudsman Program Assistant confirmed that no transfer or discharge reports had been received from the facility since March, despite the facility's internal process and staff responsibilities. The lack of documentation and confirmation of Ombudsman notification for the two residents' transfers resulted in the deficiency.