Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge notices and to notify the State Long-Term Care Ombudsman of resident transfers and discharges, as required by the State Operations Manual Appendix PP. For one resident with failure to thrive, dementia, right-sided hemiplegia, and other comorbidities, the clinical record showed a decline in oral intake, facial and eye twitching, inability to follow commands, and abnormal vital signs. The family requested transfer to the emergency room, and the resident was sent to the hospital; however, there was no documentation in the clinical record or facility documentation that the Ombudsman was notified of this transfer. Two other residents experienced planned discharges home without documented Ombudsman notification. One resident with dysphagia, dysarthria, chronic ischemic heart disease, type 2 diabetes mellitus, parkinsonism, and other conditions had a physician order for discharge home with remaining narcotics, a discharge summary and post-discharge plan of care, and a signed transfer/discharge report including personal effects and medication information. The resident was cognitively intact per a BIMS score of 15 and was discharged home, but the record contained no documentation of Ombudsman notification, and no separate facility documentation of such notification was available. Another cognitively intact resident with paroxysmal atrial fibrillation, neuropathy, and morbid obesity had a planned discharge home documented by physician order, discharge nursing summary, MDS discharge assessment, and a signed transfer/discharge report with personal effects and medication details. Again, there was no documentation of Ombudsman notification in the clinical record or elsewhere. Email correspondence from the Ombudsman office indicated they had not received discharge notices from the facility since June 2024. The Social Services Manager acknowledged she had not been notifying the Ombudsman in the required manner, and the DON stated her expectation that Social Services notify the Ombudsman but admitted the facility did not know the notification had to be in writing. Review of the facility’s discharge/transfer policy showed it did not address transfer/discharge notification to residents or their representatives, did not specify required notice content, and did not state that the Ombudsman must be notified.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.