Failure to Notify State LTC Ombudsman of Resident Discharges and Transfers
Penalty
Summary
The facility failed to ensure the discharge process included required notification to the Office of the State LTC Ombudsman for four residents whose discharges or transfers were reviewed. For a resident with muscle weakness, dementia, and a history of falls who was transferred to the emergency department after a fall, the record showed a coordinated discharge with the receiving facility but lacked documentation that the Ombudsman was notified. Another resident admitted for post-surgical care and treatment of multiple abscesses was discharged home after meeting goals and no longer requiring skilled nursing care; her record documented a coordinated discharge but did not include any indication that the Ombudsman was informed. A resident with dementia, diabetes, and neuropathy was transferred to the emergency department for cellulitis of the right lower leg, and the record reflected coordination with the receiving hospital but no documentation of Ombudsman notification. Another resident with heart failure and COPD required transfers to the emergency department on two separate occasions for COPD exacerbations; in both instances, the records documented coordination with the receiving hospital but did not show that the Ombudsman was notified of either transfer. During an interview, the Administrator confirmed that the facility did not inform the Office of the State LTC Ombudsman of these residents' discharges.
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