Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required notifications to the Ombudsman for resident transfers and discharges. One resident admitted with complete intestinal obstruction and acute kidney failure was transferred to the hospital, as documented in a progress note, but there was no corresponding documentation that the Ombudsman was notified of this transfer. During interview, the social worker stated that Ombudsman notifications were being sent quarterly and acknowledged that while on medical leave, the assistant had not been sending them, and that prior to the leave they had been sent monthly. The Chief Nursing Officer later confirmed that the required notification of this resident’s hospital transfer had not been submitted to the Ombudsman. Another resident admitted with a lower back stress fracture and left rib fracture was discharged home, with the clinical record documenting the discharge, but there was no notification sent to the Ombudsman regarding this planned discharge. In interview, the social worker confirmed that no Ombudsman notification had been made for this resident’s discharge home, and the Chief Nursing Officer also confirmed that the required notification had not been sent. These findings were reviewed with the Nursing Home Administrator, Chief Operating Officer, and Chief Nursing Officer during the exit conference.
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