Inaccurate Discharge Documentation for a Resident
Penalty
Summary
The facility failed to accurately document the discharge status of a resident, identified as Resident #100, who was reviewed as part of closed records. Resident #100 was admitted with multiple diagnoses including anemia, hypertension, hip fracture, and chronic pain syndrome. The care plan for discharge indicated the resident's or responsible party's wish to return home, with a goal to safely discharge to a lower level of care once rehabilitation goals were met. On the day of discharge, progress notes documented that the resident was discharged home via private car, accompanied by two persons, with all necessary instructions and medications provided. However, the Minimum Data Set (MDS) assessment inaccurately recorded the resident's discharge status as 'Short-Term General Hospital' instead of home. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged the error and stated that the assessment would be updated and resubmitted. The failure to accurately document the discharge status represents a deficiency in ensuring each resident receives an accurate assessment.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #100 assessment was corrected by the Clinical Reimbursement Director and resubmitted. No other residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: The Clinical Reimbursement Director/designee reviewed discharged residents for the last 30 days to ensure accurate documentation for discharge. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: The Clinical Reimbursement Director/designee will educate the Clinical Reimbursement staff on proper documentation and capturing discharge information accurately, including assessment of discharge destination. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: The Clinical Reimbursement Director/designee will audit discharge care plans and assessments for appropriate discharge status. Audits will be conducted weekly for four weeks, with findings reported monthly for three months at QAA&C or until substantial compliance is met.