Lack of Physician Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that required physician documentation for a resident's discharge was present in the medical record. Specifically, for one resident with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, acute kidney failure, and diabetes, there was no physician-documented reason for discharge or transfer. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 9, was discharged to another nursing facility due to ongoing verbal and physical aggression towards staff and self-harm behaviors. Although the facility's policy requires physician documentation to support the necessity of transfer or discharge, the medical record only contained a provider order to discharge and transfer the resident, without specifying the reason for the action. Progress notes and interviews with facility staff, including the Interim Director of Nursing, confirmed that the decision to discharge was based on the resident's escalating aggressive behaviors and the facility's inability to manage her needs. However, there was no evidence in the medical record that a physician had documented the basis for the transfer or discharge, as required by facility policy and federal regulations. This omission resulted in a deficiency related to the documentation of the discharge process.