F0628

D

Failure to Accurately Notify Ombudsman of Resident Transfers and Discharges

Macomb, Illinois Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide the state ombudsman with accurate notifications of resident admissions, transfers, and discharges as required by its own discharge/transfer policy. The facility’s undated Discharge/Transfer policy states that before a transfer or discharge, the facility must notify the resident and representative in writing, send a copy of the notice to the state long-term care ombudsman, and maintain documentation that the notice was sent. The policy also requires proper documentation of resident transfers and discharges. However, the facility’s Admission/Discharge Reports for the months reviewed did not accurately reflect all of one resident’s hospital transfers and readmissions.

The resident involved was admitted with multiple chronic conditions, including chronic respiratory failure with hypercapnia, depression, atrial fibrillation, panlobular emphysema, COPD, anxiety, stage 3 chronic kidney disease, and essential hypertension. Nursing notes document that the resident was transferred to the hospital for shortness of breath and low oxygen levels on two separate occasions and subsequently readmitted to the facility each time. The census list confirms these hospital stays and return dates, but the Admission/Discharge Reports for August and September did not include the resident’s transfer to the hospital, nor the subsequent readmissions and second hospital transfer. The ombudsman reported receiving a monthly list of admissions and discharges that she did not believe was complete and accurate, and the Administrator in Training stated that only residents absent for a specified number of days, varying by payer source, were included on the discharge sheet, resulting in incomplete reporting to the ombudsman.