Failure to Timely Notify State LTC Ombudsman of Facility-Initiated Discharge
Penalty
Summary
The facility failed to provide a timely notice of discharge to the Office of the State Long-Term Care Ombudsman for one resident. A written Notice of Transfer or Discharge for Resident 1, dated 10/21/25, showed that the resident’s spouse received the discharge notice on the same day the resident was expected to leave the facility. The notice itself stated that the facility must send a copy of the notice to a representative of the Office of the Long-Term Care Ombudsman. Facility records, including a fax transmission report, showed that the notice was not sent to the Office of the State Long-Term Care Ombudsman until 11/11/25 at 10:01 a.m., which was 22 days after the resident had been discharged. During interviews, the Social Services Director (SSD) acknowledged responsibility for sending transfer or discharge notices to the Ombudsman at the time of this event and confirmed that Resident 1’s discharge was facility-initiated. The SSD also stated she understood that the Ombudsman advocates for residents and that the notice should have been sent before the resident’s discharge. In a separate interview, Resident 1’s family member reported that the family did not request the discharge and wanted the resident to remain at the facility. The facility’s policy and procedure titled “Transfer or Discharge Notice,” dated December 2016, required that a copy of the transfer or discharge notice be sent to the Office of the State Long-Term Care Ombudsman, with notice to be provided as soon as practicable but before the transfer or discharge under certain circumstances. This policy requirement was not followed for Resident 1.
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