Late Documentation of Discharge and IDT Notes
Penalty
Summary
The facility failed to ensure timely and accurate documentation in the clinical records for two residents. For one resident, the discharge order and related progress notes, including physician notification, ombudsman notification, and interdisciplinary team (IDT) meeting notes, were documented several days after the actual discharge and associated events. The case manager confirmed that the discharge order was given and the ombudsman was notified on earlier dates, but the documentation was not completed until later due to being behind on paperwork. For another resident, the IDT meeting notes were also documented late, with the meeting having occurred months prior to the actual documentation. The social services director acknowledged that IDT meeting documentation was typically completed after the meeting. The facility's policy requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record, but this was not followed in these cases.