Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required notification to the Office of the State LTC Ombudsman regarding resident transfers and discharges. Specifically, for two residents, there was no documentation that the Ombudsman was notified when one resident was transferred to the hospital after experiencing severe respiratory distress, and when another resident was discharged after being taken out of the building by family members. Review of facility records for a four-month period revealed that no discharge or transfer notifications were sent to the Ombudsman for any residents during that time. Interviews with facility staff confirmed that the Ombudsman was not consistently notified of resident discharges or transfers, and there was no documentation to support that notifications were made. Staff described inconsistent practices, such as sometimes handing notifications to the Ombudsman in person, sending them by email, or notifying by phone, but could not provide evidence of these actions for the months in question. The Ombudsman representative also confirmed not receiving any notifications during the specified period.