F0628

D

Failure to Notify Ombudsman of Resident Hospital Transfer

Port Chester, New York Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to ensure that a copy of the notice of transfer was sent to the State Long Term Care Ombudsman for one of three residents reviewed for hospitalization, as required by 10 NYCRR 483.15(c)(3). The resident involved had diagnoses including vascular dementia with behavioral disturbance, sequelae of cerebral infarction, constipation, and atrial fibrillation, and the quarterly MDS documented short- and long-term memory problems, verbal and physical behavioral symptoms toward others, and dependence for toileting and transfers. A nursing progress note recorded that the resident was transferred to the hospital via ambulance in the early morning hours, but there was no documented evidence that a transfer notice was sent to the New York State Ombudsman for this hospitalization. During interviews, the Director of Social Services reported that Ombudsman notifications for hospitalizations and discharges were typically sent via email on a monthly basis and acknowledged they were unable to locate the notification for this transfer, and the Assistant Administrator confirmed that both Social Services and Medical Records could not find an email notification for the transfer, describing the lack of notification as an oversight.