Failure to Notify Ombudsman and Complete Physician Discharge Summary
Penalty
Summary
Facility staff failed to provide written notice to the Office of the State Long Term Care Ombudsman regarding the discharge of a resident who was admitted and later discharged home. Review of the clinical record and facility documentation revealed no evidence that the ombudsman was notified of this discharge, and staff interviews confirmed that while notifications were sent for hospital transfers, there was no confirmation or documentation for discharges to home. The facility was unable to provide any evidence of notification to the ombudsman for this resident's discharge at the time of the survey. Additionally, the facility did not ensure that a discharge summary was completed by a physician for another resident who was found unresponsive and later pronounced deceased. The medical record contained a nursing progress note and documentation of the release of remains, but lacked a physician's progress note or discharge summary. Interviews with the DON and Medical Records Coordinator confirmed that a physician note was expected but not present, and the responsible physician was no longer employed at the time of the survey.