Failure to Notify Ombudsman of Hospital Transfers and Complete Required Discharge Summary
Penalty
Summary
Surveyors determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for multiple residents. For one resident, a nursing progress note dated December 12, 2025, documented transfer to a local hospital for evaluation, but documentation provided by the Nursing Home Administrator showed that the Ombudsman was not notified, which was confirmed in an interview with an employee. Another resident’s record contained a nursing progress note dated January 17, 2026, indicating transfer to the hospital for evaluation, yet the Nursing Home Administrator’s documentation and staff interview again confirmed that the Ombudsman was not notified. A third resident was discharged to the hospital and later readmitted, but review of the clinical record did not show evidence that the Ombudsman was notified of the hospital admission, which the DON confirmed. For a closed record, a nursing progress note documented that the resident was admitted to a local hospital and discharged from the facility the same day, and review of the record and an interview with Social Services confirmed that the Ombudsman was not notified. Surveyors also found that the facility failed to complete a required discharge summary, including a recapitulation of the resident’s stay, for one closed record. For this resident, a nursing progress note documented discharge from the facility to home, and the MDS indicated the discharge was planned. However, the Nursing Home Administrator reported that the facility did not complete a discharge summary, including a recapitulation of the stay, for this resident. The Nursing Home Administrator also confirmed that the facility did not notify the Ombudsman of the hospital transfers for two of the residents reviewed. These findings were cited under 28 Pa. Code 201.14(a), Responsibility of licensee.
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