Inaccurate Discharge Paperwork Provided to Receiving Facility
Penalty
Summary
The facility failed to ensure that accurate discharge paperwork was provided to the receiving facility for a resident who was being transferred to a group home. The discharge assessment sent with the resident indicated that she required assistance with eating, hygiene, toileting, showers, lower body dressing, and putting on and taking off footwear. However, interviews and record review revealed that the resident was actually independent in these areas and did not require such assistance. The Director of Nursing confirmed that the discharge plan was incorrect and was not aware that the inaccurate assessment had been sent with the resident. The resident involved had diagnoses including asthma, tracheostomy status, and congenital malformation of the musculoskeletal system, but was cognitively intact and capable of making her own decisions. The clinical record and nursing progress notes documented the discharge planning process, including meetings with the resident and family, and the actual discharge to the group home. Despite this, the discharge narrative provided to the receiving facility did not accurately reflect the resident's functional status at the time of transfer.