Failure to Provide Complete Post-Discharge Plan of Care
Summary
The facility failed to ensure that a resident received a comprehensive post-discharge plan of care containing all necessary information for the continuation of care after discharge. The resident, who had a complex medical history including a left above-the-knee amputation, COPD, and cirrhosis with ascites, was discharged without complete documentation regarding responsible party contact information, activity levels, equipment and supplies, home health agency details, wound care instructions, ombudsman information, follow-up appointments, and pharmacy information. The discharge summary also lacked documentation of discharge diagnosis and prognosis. Interviews with facility staff revealed that while the case manager and social service staff attempted to coordinate discharge planning, there were gaps in communication and follow-through. The case manager did not make follow-up appointments as ordered, nor did she discuss the possibility of applying for additional services through Medi-Cal. The home health agency and insurance care coordinator were notified of the resident's needs, but no appointments were scheduled prior to discharge. The resident's family was left without clear instructions, leading them to contact the facility for advice when the resident experienced swelling in his leg after discharge. As a result of the incomplete discharge planning and lack of necessary information, the resident's family sent him to the emergency room within 24 hours of discharge. Facility policy and job descriptions indicated that nursing services and case management were responsible for preparing and communicating the post-discharge plan, but these requirements were not met in this instance, resulting in a breakdown in the continuity of care.
Penalty
A resident discharged after short-term rehab for a fracture received incomplete discharge paperwork, missing key pages and lacking home health agency contact information. The resident's representative was unable to reach social services for clarification and only received the full discharge summary two weeks later. There was also a discrepancy in the discharge date communicated to the home health agency.
A resident left the facility against medical advice, and although the NP notified the primary care provider and DON, the required physician discharge summary was not completed. The medical record lacked a recapitulation of the stay, final status summary, medication reconciliation, and post-discharge care plan, as confirmed by the DON.
A resident with multiple chronic conditions was discharged without a complete discharge summary as required by facility policy. Although some discharge planning and documentation occurred, the electronic medical record did not include a comprehensive summary from all departments, omitting key information such as a recapitulation of the stay and a final summary of the resident's status at discharge.
Facility staff did not complete a discharge summary, including essential sections such as the recapitulation of stay, nursing summary, and medication reconciliation, when a resident with multiple complex diagnoses was transferred to another provider. The discharge was facilitated by hospice staff, but the required documentation was not fully prepared or communicated to the receiving provider, as confirmed by record review and staff interviews.
The facility failed to complete physician discharge summaries for two residents. One resident with congestive heart failure and diabetes was discharged home after rehabilitation, while another with dysphagia and chronic kidney disease was sent to the hospital. Both lacked completed discharge summaries, as confirmed by staff interviews.
The facility failed to complete discharge summaries and medication reconciliations for two residents, impacting their continuity of care post-discharge. One resident was discharged home, and another to a hospital, both without necessary documentation. The absence of a Social Worker and inconsistent assignment of responsibilities contributed to these deficiencies.
Incomplete Discharge Summary and Communication Failure at Discharge
Penalty
Summary
Facility staff failed to provide a completed discharge summary to a resident at the time of discharge. The resident, who had been admitted for short-term rehabilitation following a hospital stay for a fall with fracture, requested to leave the facility and was discharged. Upon discharge, the resident received paperwork that was incomplete, missing several pages, and lacking contact information for the home health agency that was supposed to provide continued care. The social services note indicated that home health services were arranged, but the discharge paperwork given to the resident did not reflect this information. The complainant, who assisted the resident, reported that attempts to contact facility social services for the missing information were unsuccessful. It was not until two weeks after discharge that the complainant received a complete discharge summary via email, which included all required sections and the home health agency's contact information. Additionally, there was a discrepancy in the discharge date communicated to the home health agency, which was told a different date than when the resident actually left the facility. Review of the initial discharge paperwork confirmed that multiple sections were not filled out, pages were missing, and no contact information for the home health agency was provided.
Failure to Complete Discharge Summary for Resident Leaving AMA
Penalty
Summary
A deficiency was identified when a resident left the facility against medical advice (AMA), and the facility failed to complete a required discharge summary. The medical record review showed that the resident expressed a desire to leave AMA, and this was documented by a nurse practitioner, who notified the primary care provider via voicemail and informed the Director of Nursing (DON) about the situation. Nursing progress notes indicated that the resident left the facility accompanied by paramedical transport, with no pain or distress noted, and that the nurse practitioner was made aware of the departure. Despite these actions, the medical record did not contain a discharge summary from the physician. Specifically, there was no documentation providing a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of pre-discharge and post-discharge medications, or a post-discharge plan of care. The DON confirmed during interviews that a discharge summary should have been completed for any resident leaving the facility, regardless of the circumstances, and acknowledged that this documentation was missing.
Failure to Complete Required Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a complete discharge summary was prepared for a resident at the time of a planned discharge. According to the facility's discharge and transfer policy, a discharge summary must be completed for all residents being discharged home or transferred to another facility. This summary should include a recapitulation of the resident's stay, a final summary of the resident's status at discharge, a list of medications, follow-up appointments, and other pertinent information to ensure continuity of care. However, record review revealed that for one resident, this process was not fully followed. The resident in question had multiple diagnoses, including vascular disease, heart failure, a left shoulder cuff tear, long-term use of diuretics and anticoagulants, and a history of stroke. The resident's care plan indicated a goal of returning home with family support, and various care conferences and social service notes documented ongoing discharge planning, including referrals to assisted living facilities and coordination with the family. Despite these efforts, the medical record lacked a comprehensive discharge summary from all departments, as required by policy. Progress notes and the physician's discharge summary provided some information about the resident's medications and discharge orders, but did not include a full recapitulation of the resident's stay or a detailed final summary of the resident's status at discharge. The Director of Nursing confirmed that the electronic medical record should contain a discharge summary from all departments, including details on medications, home health arrangements, and follow-up appointments, but this was not present for the resident in question.
Incomplete Discharge Summary Provided at Resident Transfer
Penalty
Summary
Facility staff failed to complete a discharge summary, including a recapitulation of the resident's stay and a final summary of the resident's status, at the time of discharge for one resident. The resident had multiple complex diagnoses, including seizures, COPD, hypertension, anxiety, heart failure, a history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. The resident was assessed as having moderate cognitive impairment. A 30-day discharge notice was issued due to the facility's inability to meet the resident's needs and concerns for health and safety. The discharge process involved multiple staff and hospice coordination, with the hospice social worker and aide facilitating the resident's transfer to another facility. Upon review of the clinical record, the discharge summary was found to be incomplete. The section for the recapitulation of stay and summary of diagnoses was left blank, as were the nursing summary, medication reconciliation, dietary summary (except for height and weight), activities, therapy, and final disposition sections. Interviews with facility and hospice staff confirmed that the discharge summary was not fully completed or provided to the receiving provider at the time of transfer, as required by facility policy. The deficiency was discussed with facility leadership, who acknowledged the incomplete documentation and stated that the discharge was unexpected on the day it occurred.
Failure to Complete Physician Discharge Summaries
Penalty
Summary
The facility failed to ensure that a physician's discharge summary was completed for two residents who were reviewed for discharge. Resident 57, who had diagnoses including congestive heart failure and type two diabetes mellitus, was admitted for rehabilitation and discharged home after reaching rehabilitation goals. However, as of March 26, 2025, no physician's summary was completed for Resident 57's stay from January 16, 2025, to February 5, 2025. This was confirmed during a staff interview with the Director of Nursing, who stated that it is the facility's expectation for physician summaries to be completed for discharged residents. Similarly, Resident 137, who had diagnoses including dysphagia, chronic kidney disease, and hypertension, was admitted for rehabilitation after a hospital stay and was discharged after being sent directly to the hospital following an outside appointment. As of March 26, 2025, no physician's summary was completed for Resident 137's stay from December 2, 2024, to January 10, 2025. The Nursing Home Administrator confirmed during an interview that they were unable to locate a physician discharge summary for Resident 137, reiterating the facility's expectation for such summaries to be completed.
Failure to Complete Discharge Summaries and Medication Reconciliation
Penalty
Summary
The facility failed to complete discharge summaries and medication reconciliations for two residents, which are essential components of discharge planning. Resident #58, a female with a history of dementia, hypertension, and other chronic conditions, was discharged home without a discharge summary or medication reconciliation. The facility's records indicated that her care plan and interventions related to discharge were canceled, and there was no documentation of a discharge summary or medication reconciliation in her clinical records. Similarly, Resident #59, a male with severe cognitive impairment and multiple health issues, was discharged to a hospital without a discharge summary or medication reconciliation. His care plan also showed canceled discharge planning interventions, and there was no evidence of a discharge summary or medication reconciliation in his records. Interviews with facility staff, including the MDS Nurse and the DON, revealed that the facility had been without a Social Worker for about two months, and the responsibility for completing discharge summaries had been inconsistently assigned to charge nurses. The facility's policy requires a discharge summary and post-discharge plan to be developed for residents anticipating discharge, which includes a comprehensive recapitulation of the resident's stay and a final summary of their status. However, due to the absence of a Social Worker and lack of oversight, these critical components were not completed for the two residents, potentially impacting their continuity of care post-discharge. Interviews with the Administrator and previous Social Worker highlighted the facility's challenges in maintaining consistent discharge planning processes, leading to the deficiencies identified in the report.
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