Failure in Discharge Planning and Documentation
Penalty
Summary
The facility failed to ensure proper discharge planning and documentation for a resident who was discharged without prior planning or instructions. The resident, who had a history of paraplegia, anxiety disorder, major depressive disorder, cannabis dependence, and psychoactive substance-induced psychotic disorder, was admitted to the facility earlier in the month. Despite being capable of making reasonable and consistent decisions, the resident was discharged without receiving necessary discharge instructions or documentation. The discharge process was inadequately handled, as evidenced by the lack of a signed Notice of Proposed Transfer and Discharge form and the absence of documented discharge instructions. The resident was discharged without medications, as per the physician's order, and was not provided with a list of medications, prescriptions, or follow-up appointments. Interviews with staff revealed that the discharge was unplanned, and the resident insisted on leaving the facility despite the lack of medications. The staff failed to document the communication with the resident or his refusal to sign the discharge form. The facility's policy required discharge planning to begin upon admission, with the interdisciplinary team reviewing the resident's progress and determining a discharge date. However, this process was not followed, and the resident's discharge was not properly coordinated between the nursing and social services departments. The Director of Nursing and the Administrator acknowledged the importance of thorough discharge planning and documentation, which was not achieved in this case.
Plan Of Correction
Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix) Corrective action: Resident 1 no longer resides in the facility. Notice of Proposed transfer & Discharge was corrected on 3/6/25 and Faxed to Ombudsman. Late Entry for telephone order and documentation was done by RN supervisor 2 on 3/6/25. SSD called Texas Police on 3/26/25 to do a wellness check regarding Resident 1. They were unable to provide information regarding the resident's whereabouts. There wasn't anyone home at the time of their visit. How to identify potentially affected other: • On 3/21/25 Medical Records conducted an audit for Discharges from January 01, 2025, to March 21, 2025, for completion of Discharge order, Notice of Proposed Transfer, Discharge Planning, Enteract (If applicable) and Discharge notes. No other resident was found affected with the same deficient practice. Measures/Systemic change: • RN supervisor 3 was given Disciplinary Action and 1:1 in-service on 3/5/25 by DON giving emphasis on making sure that Steps for Discharge Process is done with instruction, Health teachings and Verbalization of understanding with resident's signature or Responsible Party. • RN Supervisor 2 was given Disciplinary Action and 1:1 In-service on 3/6/25 by DON Regarding Discharge Process giving emphasis on documenting and writing Telephone Order per MD's instruction for Discharges. To make sure Discharge Planning will be initiated. • License Nurses were given in-service and Re-education by Director of Nursing regarding Discharge Process on 3/6/25, 3/7/25, 3/8/25, 3/11/25 and 3/12/25 with emphasis on appropriate documentation on proposed Transfer, making sure that resident or Responsible Party will sign Discharge Instructions with Health Teachings Provided upon Discharge. • QAPI was initiated on 3/6/25 regarding Transfer and Discharges. • License nurse was given in-services by DON regarding QAPI on 3/6/25, 3/7/25, 3/8/25, 3/11/25 and 3/12/25. • The Administrator gave 1:1 in-service to Medical Records Director regarding audit on all Discharge charts on 3/7/25. • The Administrator gave 1:1 in-service to SSD on 3/24/25 regarding Discharge Process giving emphasis in Initiating Discharge Planning, Documentation and follow-up with Discharge Resident. Monitoring: • Medical Records Designee will audit the PCC, daily Discharges for charting and documentation for completion weekly. Findings will be discussed in daily clinical meeting for necessary action. • DON will review the Discharge Audit report for accuracy. Any negative trends will be discussed and reported in the monthly QA & A meeting for further intervention and compliance. Completed on 3/26/25 F 660