Failure to Notify LTCO of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required written notification to the Office of the Long-Term Care Ombudsman (LTCO) for six residents who were transferred from the facility, including five residents who were discharged home and one resident who was transferred to another facility. Review of the admission/discharge report for the period from 02/14/26 to 04/14/26 showed these six transfers, but there was no corresponding documentation that the LTCO had been notified of these discharges. During an interview, the social services staff member reported that she only notifies the LTCO when a resident is transferred to a hospital and acknowledged that she had not notified the LTCO when residents were transferred home or to another facility. In a separate interview, an administrative staff member stated that she expected that any transfers from the facility would be reported to the ombudsman. The facility was unable to provide a policy addressing notification of the ombudsman for residents transferred to another facility or discharged home when requested.
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