Failure to Document and Communicate Resident Discharge Needs and Equipment
Penalty
Summary
The facility failed to accurately document and communicate essential information regarding a resident's transfer and discharge. Specifically, the discharge summary did not include the resident's need for two transfer poles, and the discharge care plan lacked documentation of the resident's specific durable medical equipment requirements for a safe transition home. Additionally, there was no record of communication or confirmation from referral sources to ensure the resident's discharge needs were met, and the discharge date in the physician's orders was incorrect and not obtained in a timely manner. The resident, who was cognitively intact and required partial assistance with mobility and transfers, was discharged to his home with ongoing needs for specialized equipment, including two transfer poles for safe transfers. Despite therapy notes indicating the necessity of these poles and a purchase order being placed, only one transfer pole was installed at the time of discharge, and the second was not set up until later. The discharge documentation failed to reflect these needs, and the care plan did not address the equipment required for the resident's safety at home. Interviews with staff revealed that verbal confirmations regarding the resident's equipment and services were made with the home health agency and transition services team, but these communications were not documented in the resident's record. The transition services agent and supervisor confirmed that only one transfer pole was initially installed, and the second was found and installed after the resident had already been discharged. The social services director also acknowledged that the discharge date was communicated verbally but not documented.