Failure to Document Resident Discharge and Required Notifications
Penalty
Summary
A deficiency occurred when the facility failed to adequately document the discharge process for a resident with diagnoses including congestive heart failure, dementia, and myocardial infarction. The resident was admitted to the facility and later discharged to another LTC facility. Although a care plan meeting note indicated discussions about alternative living arrangements due to the resident's dementia and need for 24-hour supervision, and a Discharge MDS assessment noted the discharge, there was no documentation of a physician's discharge order in the electronic health record (EHR). Additionally, there was no other documentation or discussion of discharge or discharge planning found in the resident's EHR. The facility's policy requires a physician's order for discharge and documentation of notifications to the resident, responsible party, and family members, but these steps were not documented for this resident. The Regional Director of Operations confirmed that no additional discharge documentation was available.