Failure to Notify Ombudsman and Complete Discharge Recapitulation
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO) regarding the transfer and discharge of two residents, as required by both facility policy and regulatory standards. In the case of one resident with diagnoses including sepsis, Parkinson's disease, and aspiration pneumonia, the electronic medical record documented a hospital transfer, but there was no evidence that the LTCO was notified. Administrative staff confirmed that the notification was missed, despite being responsible for this task and the facility's policy requiring prompt notification to the LTCO after issuing a transfer notice. For another resident with chronic iron deficiency, low back pain, Barrett’s esophagus, and a cognitive communication deficit, the facility did not notify the LTCO upon the resident's unplanned discharge against medical advice. The resident, who had a history of homelessness and expressed a desire to return to living on the street, left the facility after staff and social worker consultations. Although Adult Protective Services and the local police department were notified, there was no documentation of LTCO notification. Administrative staff acknowledged that the ombudsman was not notified for this type of discharge. Additionally, the facility failed to develop a discharge summary that included a recapitulation of the resident's stay for the unplanned discharge. The discharge documentation lacked a thorough summary of the resident’s course of treatment, diagnoses, and other required information. Staff interviews revealed a lack of understanding regarding what constitutes a recapitulation, and the completed discharge summary did not meet the facility’s policy requirements for a comprehensive recapitulation of the resident’s stay.