Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of three residents who were either hospitalized or discharged. For one resident, documentation showed they were admitted from the hospital and later transferred back to the hospital due to respiratory distress, but there was no record of Ombudsman notification. Another resident, who had a history of hip fracture and dementia and was severely cognitively impaired, was transferred to the hospital after a fall and subsequent hip pain, yet no Ombudsman notification was documented. A third resident was discharged home after meeting rehabilitation goals, but again, no notification was sent to the Ombudsman. Interviews with facility staff revealed a lack of awareness and confusion regarding the responsibility for notifying the Ombudsman about resident transfers and discharges. Staff confirmed that notifications were not sent in these cases, and there was no documentation to indicate that the required notifications had been made for any of the three residents reviewed.