Failure to Notify State LTC Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide the Office of the State LTC Ombudsman with a copy of a required notice of transfer/discharge for one sampled resident. The resident was admitted to the facility and later transferred to an acute care hospital. During a closed medical record review initiated on 12/23/25, surveyors found no documented evidence that the LTC Ombudsman had been notified of this transfer. Review of the resident’s electronic medical record did not contain a completed Notification of Transfer/Discharge form or any documentation indicating that the Ombudsman had been informed of the transfer to the hospital. In an interview and concurrent record review on 1/8/26, RN 3 explained that a change of condition form, transfer form, and notice of transfer were required when transferring a resident and confirmed that all resident information was maintained in the electronic medical record. When asked to locate the Notification of Transfer/Discharge for this resident, RN 3 verified that no such notice had been completed and that there was no documentation of Ombudsman notification. In a subsequent interview on 1/12/26, RN 2, acting as interim DON, acknowledged that facility staff should have completed the resident’s notice of transfer and sent a copy to the LTC Ombudsman.
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