Incomplete Discharge Documentation and Medical Record Deficiency
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that the Discharge Planning Review Form was completed and signed by a registered nurse, and by not documenting the resident's refusal to sign discharge documents. The resident, who had diagnoses including anxiety disorder, gastroesophageal reflux disease, and acute respiratory failure with hypoxia, was admitted with intact cognition. Upon discharge, the Discharge Planning Review Form lacked both the licensed nurse's and the resident's signatures, and the resident's refusal to sign was not documented in the medical record. Additionally, licensed nurses did not document the level of care provided, the resident's health status, or the medical records given to the resident on the day of discharge. Progress notes for the resident did not reflect these required details, and the Director of Nursing confirmed that the medical records were incomplete and that documentation of the resident's discharge status was neither timely nor complete. The facility's policy required that progress notes reflect the resident's current status and be documented in a timely manner, which was not followed in this case.