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F0628
D

Failure to Notify LTCO of Resident Discharges

Coos Bay, Oregon Survey Completed on 08-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the state Long Term Care Ombudsman's office of discharges for three out of four sampled residents who were reviewed for discharges and hospitalizations. For one resident with diabetes, progress notes indicated a hospital admission, but there was no documentation that the LTCO was notified of the discharge. This was confirmed by the Regional Director of Quality Assurance. Another resident with a history of stroke was discharged, but the Ombudsman Notice of Residents Discharge form did not include this resident, and there was no documentation of LTCO notification, as verified by the same staff member. A third resident, admitted with acute respiratory failure with hypercapnia and chronic systolic heart failure, was also admitted to the hospital, but their name was not found on the Ombudsman Notice of Residents Discharge forms for the relevant months. The Social Services staff stated that a monthly fax was sent to the LTCO office listing all discharges, but no additional information was provided. Attempts to contact the LTCO office were unsuccessful, and the DNS stated that the LTCO office would be expected to be notified monthly for hospitalizations and immediately for deaths.

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