Failure to Document and Provide Discharge Instructions for Resident
Penalty
Summary
A deficiency was identified when the facility failed to document and provide discharge instructions for one of three sampled residents reviewed for closed records. The facility's policy requires that details of a resident's transfer or discharge be documented in the medical record and that appropriate information be communicated to the receiving health care provider. However, for this resident, the Discharge Instruction Form was found to be completely blank, with no information provided in any of the required sections, including patient information, responsible parties, medication education, wound care, indwelling urinary foley catheter care, and signatures. The resident in question had a history of complex medical needs, including an indwelling urinary foley catheter, multiple wound care orders, and was discharged to home with family and home health services. The medical record review showed that the resident lacked decision-making capacity, and the family member was the legally recognized decisionmaker. Despite physician orders specifying the need for home health services for PT/OT/ST, RN/LVN services for medication management, wound care, and catheter care, there was no documentation that these instructions were communicated to the resident's representative at discharge. Interviews with facility staff, including an LVN and the Medical Records Coordinator, confirmed that the discharge instructions form should have been completed and provided to the resident's representative. The absence of documentation for medication management, wound care, and catheter care instructions, as well as the lack of signatures to confirm receipt by the legally recognized decisionmaker, was verified by both staff and the Director of Nursing.