Incomplete Discharge Documentation for Resident Transfer
Penalty
Summary
The facility failed to complete the required discharge documentation for a resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, aphasia, and dysphagia. The resident was admitted with intact cognition and had a care plan to return to their previous living environment after rehabilitation. Upon review, the transfer/discharge documentation was found to be incomplete, with key sections left blank. Specifically, the 'Reason for Transfer or Discharge' was not selected from the provided options, and instead, 'Resident Request' was handwritten. The physician's order indicated approval for discharge but did not provide further details regarding the discharge reason. Additionally, the clinical record lacked comprehensive documentation from the physician related to the discharge, aside from the order to discharge. The facility's policy requires recording the reasons, effective date, and location of transfer or discharge in the medical record and on the discharge form, as well as physician documentation of medical reasons for transfer or discharge. These requirements were not met, as confirmed by staff interviews and record review, resulting in incomplete discharge documentation for the resident.