Failure to Provide Discharge Notice and Summary Documentation
Penalty
Summary
The facility failed to provide the required notice of discharge and discharge summary documentation for one of three sampled residents reviewed for closed records. Specifically, a resident who was admitted to the facility and later discharged to an assisted living facility did not have documented evidence in their medical record that they received the written notice of discharge or the discharge summary at the time of discharge. The facility's policy requires that such documentation be provided to the resident and/or their representative and included in the medical record. Interviews with facility staff, including the ADON and SSD, confirmed that the discharge process should include a transfer/discharge packet with the necessary documents, which are to be signed by the resident and documented in the medical record. However, both staff members were unable to produce evidence that these documents were completed or provided to the resident in question. The findings were acknowledged by the DSD and Administrator during the survey.