Failure to Complete Discharge Documentation and Planning
Penalty
Summary
The facility failed to ensure proper discharge planning and documentation for one resident. Specifically, the Discharge Summary did not include a recapitulation of the resident's stay, omitting details about the course of treatment while in the facility. The Post Discharge Plan of Care was incomplete, missing critical information such as the address and phone number of the discharge location, contact information for the discharge and continuing care physicians, the reason for admission and discharge, the resident's mental and psychosocial status, and care preferences. These omissions were confirmed by the Assistant Director of Nursing (ADON) during interviews and record reviews. Additionally, there was no evidence that discharge planning was incorporated into the resident's comprehensive care plan. The ADON acknowledged that a care plan for discharge planning should have been developed to establish goals for the resident's discharge and to involve the interdisciplinary team in supporting those goals. Facility policies reviewed indicated that a complete recapitulation and a comprehensive discharge summary and plan are required to ensure continuity of care and proper adjustment to a new living environment.