Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer and/or discharge to a resident, the resident’s representative, and the State Long-Term Care Ombudsman. The facility’s own “Resident Transfer and Discharge Policy and Procedure” (dated 2025) requires that, before any transfer or discharge, the facility must notify the resident and resident representative in writing, in a language and manner they understand, and must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman while maintaining evidence that the notice was sent. The policy also specifies that the written notice must include the reasons for the move, a statement of the resident’s appeal rights, the name, mailing and email address, and telephone number of the entity that receives appeal requests, information on how to obtain and complete an appeal form, and the name, address, and telephone number of the Ombudsman. The policy allows notice to be made as soon as practicable when an immediate transfer or discharge is required by urgent medical needs. Resident #2 was admitted in November 2025 with diagnoses including encephalopathy, vascular dementia with behavioral disturbance, TIA, alcohol abuse, and wandering. Nursing progress notes showed that this resident was transferred from the facility and admitted to the hospital on two occasions, on [DATE] and again on 12/15/25. Review of the medical record revealed no documentation that the facility provided written notification of the transfer and/or discharge to the resident or the resident’s representative, and no documentation that a copy of such notice was sent to the State Long-Term Care Ombudsman for the transfers occurring on 11/26/25 and 12/15/25. In an interview on 01/20/26 at 4:05 P.M., the Director of Social Services confirmed she could not provide any documentation to support that the required written notifications or Ombudsman copies had been provided for these transfers.
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.