Failure to notify the State Ombudsman Office of a resident discharge. A resident admitted for short-term respite care with multiple neurologic and psychiatric diagnoses was discharged, but the record showed no evidence that the Ombudsman was notified. The SSD stated non-emergent discharges were usually reported by email, but she could not provide proof of notification and said she was unaware a written Notice of Transfer also needed to be sent after discharge.
The facility failed to notify the Ombudsman in writing of an unplanned discharge for a resident with acute respiratory failure with hypoxia, ESRD, DM2, and COPD. The QI Nurse stated only hospitalizations were reported, and the SSD confirmed she was only aware of reporting hospitalizations and did not report the resident’s discharge to the Louisiana Ombudsman Program.
Failure to notify the Ombudsman of a resident discharge: A resident with COPD, chronic systolic CHF, and chronic atrial fibrillation had an unplanned discharge home, but the facility did not report the discharge to the Louisiana Ombudsman Program. The ADON stated the resident had been admitted for therapy and later the family decided to discharge the resident suddenly, while the SSD confirmed she only reported hospitalizations and did not report the discharge.
Failure to Notify Ombudsman of Resident Discharges: The facility failed to send written transfer/discharge notices to the Ombudsman for two residents reviewed. One resident was discharged home with HH skilled PT/OT after fractures of the hand, ribs, and thumb, and another resident with femur and humerus fractures plus disorientation was discharged after an ER transfer order for chest pain. The BOM stated she was responsible for reporting the transfer logs but was unaware planned or actual discharges had to be reported.
Failure to provide bed hold policy at transfer. The facility did not document that a resident or the resident's representative was given the bed hold notice when the resident was transferred to the hospital. The resident had multiple serious diagnoses, including aneurysm, GI hemorrhage, anemia, COPD, pulmonary edema, and CHF, and the DON confirmed there was no record that the policy was provided during the hospital transfers.
A resident was discharged from the facility without a required discharge summary being completed, contrary to the facility’s own policy that mandates a discharge summary and post-discharge plan for anticipated discharges to a private residence or another nursing care facility. Record review showed the absence of any discharge summary in the resident’s medical record, and the SSD confirmed during interview that no discharge summary had been completed.
The facility failed to notify the State LTC Ombudsman in writing of a resident’s emergency hospital transfer and failed to give the resident and RP written notice of the bed-hold policy duration at the time of transfer. The transfer log did not show the resident was entered for the hospital transfer, and the Corporate Nurse stated the Ombudsman was not notified and the bed-hold policy was not completed.
A resident with multiple chronic conditions and recent fractures was transferred to another facility without proper documentation of the discharge date, time, events, or a discharge summary in the medical record. The ADON confirmed the absence of required discharge documentation.
The facility did not send required discharge notices to the State Long-Term Care Ombudsman for two residents who were discharged, as confirmed by missing documentation and staff interviews. Emergency transfer logs were incomplete, only covering a single month, and prior records were not accessible.
A resident had an emergency transfer to a local hospital, but the facility's Ombudsman emergency transfer list did not include the transfer and there was no other evidence that the State LTC Ombudsman was notified in writing. The Assistant Administrator confirmed the omission, and the DON stated the transfer should have been listed as required.
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