Failure to Timely Notify Ombudsman of Resident Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide timely notification to the State LTC Ombudsman via the Aging and Disability Services application portal when residents were discharged or planned for discharge. For one resident with type 2 DM with foot ulcer, chronic osteomyelitis, and cellulitis, the facility granted an independent leave of absence, documented the expected return time, and later documented that the resident would return the following morning and would miss medications. The resident was subsequently found intoxicated, hypothermic, and later expired in the ED, and the facility could not provide evidence that a discharge notice was uploaded to the portal. Interviews with the social worker and DNS confirmed that this resident’s situation was considered a transfer rather than a discharge and that no ombudsman notification was made. For multiple other residents with complex medical conditions, including osteomyelitis, peripheral vascular disease, gas gangrene, coronary artery disease, renal insufficiency, COPD, heart failure, respiratory failure, depression, multiple sclerosis, schizoaffective and anxiety disorders, the facility issued written Notices of Intent to Discharge, generally providing 30‑day notices due to improved health, acceptance into Money Follows the Person programs, or family choice to return home. Social service notes documented discharge planning meetings with residents, families, therapy, and MFP representatives, as well as the actual discharge dates. However, the corresponding discharge notices were not uploaded to the Aging and Disability Services application portal at the time the notices were given to the residents. Instead, the discharge notifications for these residents were uploaded days to more than a month after the Notices of Intent to Discharge were issued, with delays ranging from 1 to 37 days. Interviews with the social worker and DNS showed that facility staff were unable to identify a specific timeframe for when discharge notices must be created and uploaded to the portal and believed there was no defined deadline. This practice conflicted with the facility’s Transfer/Discharge policy and the CMS regulation requiring that a copy of the discharge notice be sent to the State LTC Ombudsman at least 30 days prior to discharge or as soon as possible, and at the same time the notice is provided to the resident and resident representative.
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