Failure to Provide Complete Discharge Summaries and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide a final summary of the resident's status at discharge for two residents, resulting in incomplete documentation of their care and discharge process. For one resident with multiple complex diagnoses, including malnutrition, cerebral palsy, rectal cancer, muscle weakness, depression, dysphagia, and anemia, the records showed that although the discharge plan indicated a comprehensive summary would be developed, the actual discharge charge summary was undated and lacked a recapitulation of the resident's stay. Nursing notes documented the resident's departure, refusal of medication, and that paperwork was sent with the resident, but did not include a comprehensive summary as required by facility policy. For another resident with diagnoses such as respiratory failure with hypoxia, dyspnea, insomnia, anxiety, and COPD, the records indicated that the resident was transferred to the hospital. Staff interviews revealed that while the bed-hold policy was verbally communicated and sent with the resident, written notification to the resident's legal representative was not consistently provided at the time of transfer. The facility's policy required that written information about the bed-hold policy be given upon admission and upon transfer, but this was not always documented as completed. Facility policies specified that both nursing and social services staff are responsible for developing a discharge summary that recapitulates the resident's stay and status at discharge to ensure continuity of care. However, in these cases, the required documentation was either incomplete or missing, and written notifications regarding bed-hold policies were not always provided as required. These deficiencies were confirmed through record review and staff interviews.