Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
Surveyors found that the facility failed to notify the Office of the State Long-Term Care Ombudsman about a resident’s hospitalization as required. The resident had diagnoses including metabolic encephalopathy and sequelae of cerebral infarction and was transferred from the facility to the hospital and subsequently admitted on two separate occasions, December 26, 2025, and January 1, 2026. Review of the facility’s Ombudsman transfer/discharge reporting documentation for December 2025 and January 2026 showed that this resident was not included on the monthly transfer/discharge lists submitted to the Ombudsman. During an interview, the Nursing Home Administrator confirmed that the resident was not on the Ombudsman reporting lists for those months and explained that a change in computer programs had resulted in residents who had elected bed-hold status not being generated on the transfer/discharge list. The Administrator also confirmed that it was the facility’s expectation that transfers and discharges be accurately reported to the Ombudsman’s office. This failure to report the resident’s hospital transfers and admissions constituted noncompliance with 28 Pa Code 201.14(a) and 201.18(b)(3).
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