Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
Surveyors determined that the facility failed to notify the Ombudsman of a resident’s hospital transfers as required. The resident, admitted on 1/6/22, had a nephrostomy tube and experienced multiple hospitalizations related to that device. Progress notes showed that the resident’s POA was notified when the resident was hospitalized on 11/13/24 after the nephrostomy tube was dislodged, again on 12/26/24 for pain at the nephrostomy site and a UTI diagnosis, and on 5/11/25 for another dislodgement of the nephrostomy tube. However, review of the resident’s hospital transfer paperwork and the facility’s monthly Ombudsman reports revealed that the Ombudsman was not notified of these three hospital transfers, and the resident’s name did not appear on the Ombudsman reports for November 2024, December 2024, or May 2025. These findings were confirmed with the NHA during the survey and discussed with facility leadership at the exit conference. The deficiency centers on the facility’s omission of required Ombudsman notification for the resident’s repeated hospitalizations, despite documentation that the POA had been informed and that the transfers were recorded in the medical record and transfer paperwork.
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