Failure to Provide Discharge Instructions and Medications During Resident Transfer
Penalty
Summary
The facility failed to follow its policy regarding the provision of discharge instructions and medications for a resident who was transferred to another skilled facility. The resident had a planned discharge, and the family was responsible for transporting her. According to staff interviews, the family took the resident without speaking to the nurse on duty, and the nurse was unaware of the resident's departure until contacted by the admitting facility. As a result, no medications or discharge instructions were sent with the resident at the time of transfer. Documentation reviewed showed that while a transfer discharge report and discharge planning review were prepared, there was no evidence of a signed discharge instruction form or confirmation that instructions and medications were provided to the resident or her representative on the day of discharge. Progress notes indicated that the resident had requested the transfer and that the family would handle transportation. However, the nurse only became aware of the resident's departure after being notified by the receiving facility, which reported that no medications had accompanied the resident. The facility's policy requires that discharge instructions, medication lists, and any necessary referrals be reviewed and sent with the resident, and that documentation be signed by the resident or their representative. These steps were not completed, and the required documentation was not presented for review.