Failure to Notify Ombudsman of Resident Discharge to the Community
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the Ombudsman of a resident’s discharge to the community. Record review showed that on 7/3/25 at 2:30 PM, a nurse progress note documented that the resident’s daughter arrived at the facility to pick up the resident, who was discharging home to live with her daughter. Review of the facility’s April 2025 Transfer Log on 8/28/25 at 1:15 PM lacked any evidence that the Ombudsman was notified of this discharge to the community on 7/3/25. In an email dated 8/28/25 at 4:09 AM, the Nursing Home Administrator (E1) documented that the Ombudsman was notified that day of the resident’s discharge home, and in a follow-up interview on 8/29/25 at 8:39 AM, E1 confirmed that the Ombudsman had not been notified of the resident’s discharge when the July 2025 list was submitted to the Ombudsman on 8/15/25. Findings were subsequently reviewed with the Nursing Home Administrator (E1) and Director of Nursing (E2) on 8/29/25 at 1:33 PM, and again during the exit conference on 8/29/25 at 2:30 PM with E1, E2, and the Assistant Director of Nursing (E5).
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.