Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman when a resident was discharged and admitted to the hospital on two separate occasions. Interviews with facility staff, including the Minimum Data Set coordinator, Director of Staff Development, Director of Nursing, and Social Services Director, confirmed that notification of the Ombudsman is required by facility policy and is considered essential for resident safety. Record reviews verified that the resident was transferred to the hospital on two specific dates, but there was no documentation indicating that the Ombudsman had been notified of these transfers. The facility's policy and procedure on transfer and discharge notices, as well as state guidance, require that notice of transfer or discharge be provided to the Ombudsman. Despite this, the Social Services Director acknowledged that no documentation existed to show that the Ombudsman was notified for the resident's hospital transfers. This omission was confirmed through interviews and record reviews, establishing that the required notifications were not made as per policy.