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.
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.
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 was transferred to a hospital emergency room and returned, but the required transfer notice was not sent to the State LTC Ombudsman due to missing documentation in both the Emergency Transfer Log and Census Change Sheet. Staff interviews revealed that the responsible LPN was unaware of the requirement to document the transfer, resulting in the omission.
Two residents were transferred to hospitals or rehabilitation facilities without receiving the required written notice specifying the duration of the bed-hold policy at the time of transfer. Record reviews and staff interviews confirmed that neither the residents nor their responsible parties received or signed the necessary documentation, despite facility policy requiring this notification during such events.
Two residents were discharged without complete discharge summaries, missing required information such as a recapitulation of their stay, final status at discharge, and medication reconciliation. Documentation was either incomplete or missing key details, and staff confirmed that the necessary discharge information was not provided or properly recorded.
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