Failure to Document Discharge Planning and Family Communications in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents who were undergoing discharge planning. For one resident with moderate cognitive impairment, the care plan did not reflect a discharge plan, despite documented requests from the resident's family for referrals to other facilities. Although care conference notes indicated these requests, there were no progress notes from the Social Services Representative in the resident's electronic health record (EHR) since admission. The Social Services Representative confirmed that she had not documented any interactions or actions taken regarding the resident's transfer requests, and only provided email correspondence with the family as evidence of communication. For another resident, also with moderate cognitive impairment, care conference notes and interviews confirmed ongoing discussions between the Social Services Representative and the resident's family about transferring to a different facility. However, there were no progress notes in the EHR documenting these interactions or updates on the transfer process, with the last note being unrelated to discharge planning. The Social Services Representative acknowledged not documenting these interactions, and the Chief Nursing Officer confirmed that all such interactions should be recorded in the EHR. Facility policy required documentation of communications with residents and their representatives, as well as referrals and discharge plans, but these were not present in the records reviewed.