Failure to Notify Ombudsman of Emergency Hospital Transfers
Penalty
Summary
The facility failed to provide required written notification to the Ombudsman regarding residents’ emergency transfers to the hospital. For one resident, identified as Resident #99, nursing progress notes documented that the resident was out of the facility for an appointment and was transferred to the hospital for further evaluation due to chest pain. The medical record showed that this resident was discharged from the facility on the same day and did not return. The facility was unable to produce any documentation that the Ombudsman was notified in writing of this emergency transfer and discharge. For another resident, identified as Resident #88, nursing progress notes documented two separate emergency transfers to the hospital related to seizures and seizure-like activity, one initiated at the request of a family member. The medical record showed that the resident was discharged to the hospital on both occasions and later returned to the facility. In both instances, the facility could not provide documentation that the Ombudsman was notified of the emergency transfers. During interviews, the Social Worker stated she had not sent any Ombudsman notifications for emergency transfers since being hired and did not know who was responsible for doing so, while the interim Ombudsman reported that no emergency transfer notifications had been received from the facility since a prior month. The Administrator stated he was unaware that notifications had not been sent and believed it was the Social Worker’s responsibility to notify the Ombudsman of emergency hospital transfers.
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