Failure to Timely Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide timely notices of discharge to the ombudsman for three sampled residents who were transferred to a general acute care hospital. For one resident with severe cognitive impairment and total dependence on staff, the Notice of Proposed Transfer/Discharge (NPTD) was not faxed to the ombudsman until several days after the transfer, despite the facility's policy requiring immediate notification. The responsible party received the notice on the day of transfer, but the ombudsman was notified late, as confirmed by the Registered Nurse Supervisor during record review and interview. Another resident, who had intact cognition but required varying levels of assistance with daily activities, was transferred due to difficulty swallowing. The NPTD was provided to the resident on the day of transfer, but the ombudsman was not notified until the following day. Similarly, a third resident with metabolic encephalopathy and respiratory failure was transferred for medical treatment, and while the resident received the NPTD on the day of transfer, the ombudsman was notified two days later. In both cases, the facility's transmission logs confirmed the delays in notification to the ombudsman. Interviews with facility staff, including the DON and Medical Record Director, revealed that the facility's policy required the ombudsman to be notified at the same time as the resident or their representative, but the policy language was unclear and not consistently followed. The Medical Record Director acknowledged being responsible for faxing the NPTD but cited being busy as the reason for the delays. The facility's own policy and procedure documents confirmed that notification to the ombudsman should occur concurrently with notification to the resident or representative, and that temporary transfers to acute care are considered facility-initiated discharges.