Failure to Provide Complete Discharge Documentation and Information
Penalty
Summary
The facility failed to provide complete and accurate discharge documentation for two residents who were discharged home. For one resident with multiple complex medical conditions, including acute respiratory failure, COPD, diabetes, and chronic embolism, there was no Post-Discharge Plan of Care found in either the electronic or hard medical record. Interviews with the resident's family and facility staff confirmed that the resident was not given a medication list, wound care instructions, or information about home health agency (HHA) services upon discharge. The family reported being unprepared and having to contact the primary care physician for assistance after discharge. For another resident with a history of fractures, COPD, heart failure, diabetes, and anxiety disorder, the discharge summary was incomplete. Although the resident was sent home with some discharge paperwork and a medication list, the Post-Discharge Plan of Care assessment lacked critical information such as the HHA's contact details, Ombudsman contact, wound care orders, primary care physician, and pharmacy information. The resident's family had difficulty arranging for durable medical equipment (DME) due to missing contact information and reported that the resident was discharged without the necessary equipment being delivered. Facility policy required that a discharge care plan be included in the medical record for resident-initiated discharges, aligning with the resident's goals and desired outcomes. However, in both cases, the required documentation was either missing or incomplete, as verified by staff interviews and record reviews. This deficiency was identified during a complaint investigation and affected two of three residents reviewed for discharges.