Failure to Timely Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to send copies of transfer or discharge notices to the State LTC Ombudsman in a timely manner for four residents who were reviewed for admission, transfer, or discharge. The Social Services Director had informed the Ombudsman by email that the secured memory care unit was being transitioned to an unsecured long-term care unit and that residents on the unit were being reviewed for appropriate placement, with the Ombudsman to be copied on any involuntary discharge notices. The Ombudsman responded requesting a resident list, their discharge plans, and indicated she would watch for transfer/discharge notices by email. Notices of transfer or discharge for four residents were issued in late September and early October, with three residents being discharged to another nursing facility and one resident discharged shortly thereafter. Record review showed that the notice of transfer or discharge for one resident was issued on 10/2/25, and for three other residents on 9/22/25, with corresponding discharge dates later in September and early October. However, the Social Services Director did not email the notices of transfer or discharge for these four residents to the Ombudsman until 11/21/25, after all four residents had already been discharged from the facility. During interview, the Social Services Director acknowledged there had been a delay in sending the notices. The facility’s own policy on inappropriate discharge prevention required issuing the Notice of Transfer or Discharge and Appeal Rights at least 30 days prior to transfer and sending a copy to the local and State Ombudsman, as well as providing the resident and responsible party with a copy of the bed-hold policy.
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