Failure to Notify State LTC Ombudsman of Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to send a copy of the notice of discharge to the representative of the Office of the State Long Term Care Ombudsman for one of three sampled residents reviewed for closed records. The facility's policy and procedure required that evidence be maintained showing the Ombudsman was notified for non-emergency transfers or discharges initiated by the facility. However, upon review of the closed medical record for the resident in question, there was no documentation indicating that the Ombudsman had been notified of the discharge. The resident was admitted to the facility and later discharged to home with medications, as indicated by a physician's order and progress notes. Discharge instructions were provided to the resident's caregiver, and the resident was discharged home. Despite these actions, the medical record did not contain any evidence that the required notification to the State LTC Ombudsman had been completed. Interviews with the Medical Records Director and the Social Services Director (SSD) confirmed that neither could provide documentation of the Ombudsman notification for the resident's discharge. The Medical Records Director also indicated that there was no documentation in the resident's medical record and was unsure if a separate log book existed for such notifications. The SSD similarly verified the absence of a copy of the Ombudsman notification. The findings were acknowledged by the facility's Administrator, Administrator Assistant, and DON.
Plan Of Correction
4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON and Administrator will monitor the effectiveness of the process, and any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025. 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 86 was affected by this deficient practice. Immediately, the Unit Manager updated Resident 86's care plan to reflect oxygen administration parameters. On 8/5/2025-8/8/2025, the DON provided 1:1 education to LVN 12 and in-serviced all Licensed Nurses about facility policy and procedure of developing comprehensive care plans for each resident, in particular care plans for oxygen administration. The DON also in-serviced staff about policy and procedure for assessing residents' medical needs to ensure the care plan was updated. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents receiving oxygen could potentially be affected by this deficient practice. The DON and Unit Managers audited all residents' care plans who were receiving oxygen and found no other issues. The DON will provide ongoing education and training to Licensed Nurses about developing comprehensive care plans for individual residents. 3. Measures that will be put into place or systematic changes the facility will make to ensure that the deficient practice does not recur: The DON or designee will oversee this process. The DON or designee will review all new admissions and re-admissions for oxygen orders and will ensure comprehensive care plans are developed to include oxygen parameters, especially for residents receiving oxygen. Any findings will be reviewed and reported during clinical meetings. Medical record audits of oxygen orders will be conducted to ensure the care plan reflects the resident's oxygen administration parameters for three months, with reports to the DON for any non-compliance.