Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide written notification to the ombudsman regarding the transfer and subsequent discharge of a resident to a behavioral hospital. The resident, who had diagnoses including schizophrenia, unspecified psychosis, and major depressive disorder, was admitted with moderate cognitive impairment. Due to an escalation in verbal, physical, and violent behavior towards staff, the facility initiated an immediate discharge and transferred the resident to a hospital for psychological evaluation. Although the family member was notified by phone, the resident, who was his own responsible party, refused to give verbal consent for the discharge. Documentation review revealed that the social worker (SW) claimed to have contacted the ombudsman by leaving a voicemail regarding the immediate discharge, but there was no documentation of this action, nor could the SW provide a date for the attempted notification. Additionally, the SW could not produce a copy of the original 30-day notice or confirm its delivery. The ombudsman later confirmed that no notification was received before or after the resident's discharge. Interviews with facility staff, including the DON and ADM, indicated that they were unaware the ombudsman had not been properly notified. The facility's policy requires notification of the ombudsman for all discharges, but this was not followed in this instance. The lack of written notification to the ombudsman constituted a failure to ensure the resident's rights regarding transfer and discharge were upheld.