Failure to Document Physician Basis for Resident Discharge
Penalty
Summary
The facility failed to ensure that the discharge process was properly followed for a resident, as required by its own policies and procedures. Specifically, the closed medical record for the resident did not contain documentation from the attending physician indicating the basis for the resident's discharge. The facility's policy states that the attending physician must document the reason for transfer or discharge in the clinical record, particularly if the discharge is due to the resident's welfare or improvement in health. However, a review of the resident's medical record revealed that, prior to providing the resident with the Letter of Continued Determination (LCD), there was no physician documentation supporting the discharge decision. Further review of the resident's history showed that the resident was admitted, had a physician's order for discharge, and was later transferred to an acute care hospital. The History & Physical examination indicated ongoing need for in-patient therapy, and there was no indication that the resident was ready for discharge based on physician documentation. Interviews with the Social Services Director and the Administrator confirmed the absence of required physician documentation correlating with the discharge planning and progress notes.