Failure to Notify Ombudsman of Resident Transfer and Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to notify the Office of the State Long-Term Care Ombudsman (OSLTCO) of a resident’s non-emergency transfer to another skilled nursing facility at the same time notice was provided to the resident. The resident was admitted with diagnoses including unspecified dislocation of the left knee (subsequent encounter), unspecified paraplegia, unspecified depression, and generalized muscle weakness, and had an admission MDS BIMS score of 14, indicating intact cognition. A referral for transfer from one SNF to another was initiated on February 6, 2026, at the resident’s request, and social services documented that SNF-to-SNF transfer procedures were discussed with an individual initially identified as a family member/POA, who later clarified she was not a family member or POA but had the resident’s consent to receive information. On February 10, 2026, the facility issued a written notice of transfer/discharge with an effective date of the same day, citing that the resident’s health had improved sufficiently and she no longer required the facility’s services, and informing her that any appeal would need to be filed within 10 days of the notification. Nursing documentation on that date recorded that the resident left the facility and that a discharge assessment was completed, and that the transfer was reported to a POA/family member. However, there was no documentation in the clinical record or progress notes showing that the OSLTCO was notified of the transfer/discharge at the same time as the resident, nor was there evidence of additional detail regarding discharge planning discussions or inclusion of discharge planning in the resident’s care plan. In interviews, the OSLTCO stated that they had not received the discharge notice in a manner that would allow advocacy for the resident’s appeal rights and clarified that, aside from emergency hospital transfers or deaths (which may be reported monthly), facilities must provide notice of discharge to the resident or representative at least 30 days before discharge for other types of discharges. The resident reported that a male staff member told her she had been admitted to the wrong facility because it was a short-term facility and that she would need to look into another facility for long-term care, which upset her and influenced her desire to transfer. She stated she received notification of a potential placement the day before discharge, signed a document with only an initial, and was unaware of her right to appeal the transfer/discharge or to discuss the transfer with an ombudsman until later. The social services director and DON both stated they believed ombudsman notifications were done monthly and were unaware of additional expectations for notification related to non-emergency transfers, and there was no facility policy addressing ombudsman notification.
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.