Failure to Complete Discharge Documentation, Bed Hold Notices, and Ombudsman Notification
Penalty
Summary
The facility failed to complete required documentation and notifications related to resident discharges and transfers, affecting four residents reviewed for discharges. Specifically, the facility did not complete discharge summaries or recapitulations of residents' stays, did not provide bed hold notices when residents were transferred to the hospital, and failed to notify the Ombudsman of resident discharges in a timely manner. These deficiencies were identified through medical record reviews, staff interviews, and policy reviews. One resident with multiple chronic conditions, including COPD, diabetes, hypertensive heart disease, and kidney cancer, was discharged without a documented recapitulation of their stay, and the Ombudsman was not notified of the discharge. The discharge summary was signed after the resident had already left the facility. Another resident with end stage renal disease, atrial fibrillation, and major depressive disorder was sent to the hospital and subsequently discharged, but the Ombudsman was not notified until months later. A third resident with diabetes, peripheral vascular disease, and depression was discharged to another facility, and again, the Ombudsman notification was delayed. Additionally, a resident who was transferred to the hospital did not receive a bed hold notice, and there was no documentation of the bed hold offer or the resident or responsible party's decision in the medical record. Staff interviews confirmed these lapses, and policy reviews indicated that the facility's own procedures require timely discharge documentation, bed hold notifications, and Ombudsman notification, none of which were consistently followed in these cases.