Missing transfer notices and emergency transfer log entries. The facility failed to provide required written transfer/bed-hold notice to one resident and failed to document emergency transfers in the Ombudsman log for three residents. Affected residents had significant medical histories including CVA, ICH, respiratory failure, DVT, bipolar disorder, Parkinson’s disease, and schizoaffective disorder, and were transferred to the ER/hospital without the required documentation found in the record.
A resident's discharge summary failed to include a recapitulation of the resident's stay and course of treatment, even though the resident was discharged to another facility. The record showed the resident left with a staff driver, and staff attempted to give report by phone but did not reach the receiving facility. The SSD and ADON both confirmed the discharge summary was incomplete.
A resident with emphysema, HF, nutritional anemia, cocaine use, HTN, and unspecified viral hepatitis C was discharged after a hospital transfer, but the discharge was not listed on the facility’s March emergency transfer log. The SSD stated discharges were reported monthly to the Ombudsman and confirmed the resident should have been included, and the Adm also confirmed the resident was not on the log but should have been.
A facility failed to provide written bed hold and appeal notices to three residents transferred to the hospital, including residents with acute respiratory failure, CKD, COPD, dementia, and other chronic conditions. The facility also did not update the Ombudsman emergency transfer log for two residents, and staff interviews confirmed the missing documentation and notifications.
A resident admitted with acute and chronic respiratory failure with hypoxia was discharged from the facility, but the Ombudsman Notification log did not show that the LTC Ombudsman was notified. An LPN stated she had not reported discharges to the Ombudsman for months and confirmed she was responsible for submitting the notification log; the Administrator also confirmed the facility did not provide 30-day notices to the Ombudsman.
Failure to Notify Ombudsman of Resident Discharge: A resident with hemiplegia and hemiparesis following CVA had an unplanned discharge, but the facility did not report the discharge to the state Ombudsman program. The SSD stated she only knew to report hospitalizations using the Emergency Transfer Log and confirmed the discharge was not reported.
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.
A resident with COPD, Type 2 DM with diabetic neuropathy, and acute respiratory failure with hypercapnia was discharged home with HHC after a planned discharge order. The facility's discharge log did not include the resident's discharge, and the Accounts Manager stated she only reported emergency transfers and was unaware that non-emergency transfer/discharges also had to be sent to the Ombudsman Program. The DON confirmed the discharge was planned, and the resident's discharge was not submitted for Ombudsman notification.
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.
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