Failure to Obtain Physician Order and Complete Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to follow its policy and procedure for discharge planning and documentation for one resident who was transferred to a general acute care hospital for psychiatric evaluation. The resident, who had diagnoses including schizophrenia and anxiety disorder, was transferred due to physical aggression. Upon review, it was found that there was no physician's order for discharge and no discharge summary completed in the resident's medical record. The Social Services Assistant (SSA) initiated the discharge notification but did not provide a bed hold notice, based on communication from the case manager indicating the resident would not return. The Licensed Vocational Nurse Supervisor (LVNS) did not obtain a discharge order or complete the discharge summary, stating she was unaware of the discharge decision and was occupied with other duties. Interviews with facility staff confirmed that the required discharge documentation was not completed, and there was a lack of communication between the SSA, LVNS, and the case manager regarding the resident's discharge status. The administrator acknowledged that the nurse should have obtained a physician's discharge order and completed the discharge summary to ensure proper and safe discharge. Review of the facility's policy indicated that a discharge summary and post-discharge plan should be developed when a resident's discharge is anticipated, but this was not done in this case.