Inaccurate Documentation of Discharge Disposition
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's discharge disposition in the medical record. A review of the resident's records showed inconsistencies: the Admission Record indicated admission with diagnoses including atrial fibrillation, shortness of breath, and muscle weakness. The Discharge Planning Review noted the resident requested discharge to another LTC center, and the Discharge Instruction Form confirmed discharge to a LTC center. However, the Minimum Data Set (MDS) documented the resident as being discharged to a short-term general hospital. During interviews, the MDS Coordinator acknowledged incorrectly documenting the discharge destination in the MDS, while the Discharge Instruction Form reflected the correct LTC center destination. The Director of Nursing confirmed that accurate documentation in the medical record is essential for quality care and impacts the development of the care plan and post-discharge support. The facility's policy requires that documentation be objective, complete, and accurate. The discrepancy between the MDS and the Discharge Instruction Form resulted in incomplete and potentially misleading information regarding the resident's discharge status.