Failure to Document Discharge Instructions for Resident with Complex Care Needs
Penalty
Summary
The facility failed to ensure that discharge instructions were properly documented for one of two sampled residents reviewed for discharge. The resident, who had multiple diagnoses including obstructive uropathy, s/p left nephrostomy, AKI on CKD 3, bladder cancer, hypertension, CVA, and chronic CHF, was determined to have the capacity to understand and make decisions. The resident's Post Discharge Plan of Care and Summary lacked entries in sections related to Foley catheter care and other special care instructions. Additionally, the Skilled Evaluation Notes for several days prior to discharge did not contain any documentation under the Education/Notification section. Interviews with the DON and DSD confirmed that there was no documentation in the resident's progress notes, Post Discharge Plan of Care and Summary, or Skilled Evaluation Notes indicating that the resident was provided with education or instructions regarding their specific care needs, such as Foley catheter and nephrostomy care, prior to discharge. Both the DON and DSD acknowledged that this information should have been documented if provided. The Administrator and DON verified these findings during the review.