Pelican Health Randolph LLC failed to notify the ombudsman in writing when Resident #88 went home on July 22, violating federal requirements designed to protect residents' rights during care transitions.
The resident had been at the facility for long-term antibiotic treatment. A nursing note from 10:11 AM on July 22 documented his discharge home at 10:00 AM with a family member. Staff provided self-care education and the resident verbalized understanding before leaving.
But no transfer or discharge notice was ever issued.
The ombudsman told inspectors during a September 10 phone interview that she hadn't received any transfer or discharge lists from the facility since May 2025. She wasn't familiar with Resident #88's discharge home.
The breakdown occurred during a period of significant staffing turnover in key positions responsible for resident notifications.
The facility's former social worker, employed from June through August 2025, told inspectors she was still in training during her entire tenure. During a September 12 phone interview, she revealed she didn't send notifications to the ombudsman and wasn't aware this was required.
She said the administrator handled transfer and discharge details.
The former director of nursing confirmed during a September 17 interview that Resident #88 had completed his planned antibiotic treatment and had a scheduled discharge home. She said the former social worker was responsible for communicating all transfer and discharge information to the ombudsman.
The administrator acknowledged the communication failure during her September 15 interview with inspectors. She said the facility currently had no social worker but expected the facility to communicate transfer and discharge lists to the ombudsman.
The administrator told inspectors she had since contacted the ombudsman and sent the missing transfer and discharge lists.
Federal regulations require nursing homes to notify ombudsmen of resident transfers and discharges to ensure advocacy services remain available during vulnerable transitions. The ombudsman program provides independent oversight of nursing home care and investigates complaints on behalf of residents.
The inspection found the facility's electronic medical record contained no evidence of the required discharge notification for Resident #88. The ombudsman's lack of knowledge about his discharge confirmed the notification never occurred.
The violation occurred during a critical staffing gap. The social worker responsible for ombudsman communications was new to her role and inadequately trained on federal notification requirements. She left her position at the end of August, leaving the facility without dedicated social work coverage.
The former director of nursing's expectation that the social worker would handle ombudsman notifications conflicted with the social worker's understanding that the administrator managed discharge details. This confusion left Resident #88's discharge unrecorded with the ombudsman.
The administrator's acknowledgment that she expected ombudsman communication but failed to ensure it occurred during the social worker transition demonstrates a breakdown in supervisory oversight of federal compliance requirements.
The facility's failure to send any transfer or discharge lists to the ombudsman since May 2025 suggests the notification problem extended beyond Resident #88's case. The administrator's post-inspection contact with the ombudsman to provide missing lists indicates multiple unreported discharges during the summer months.
Resident #88 completed his antibiotic treatment and returned home with his family, but the state ombudsman never knew he had been at the facility or that his care had ended.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Health Randolph LLC from 2025-09-17 including all violations, facility responses, and corrective action plans.