Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to ensure that discharge documentation for a resident was fully completed. Upon review of the resident's closed medical record, it was found that several sections of the Engage Discharge Planning Tool were left blank, including responsible parties' information, primary physician information, staff and resident or responsible party signatures, and the medication list. Additionally, the section regarding whether a pharmacy printout of the medication regimen was attached was not completed, and no medication list or indication of its status was present in the record. Interviews with facility staff revealed that the discharge paperwork is typically initiated by the social worker and completed by various disciplines, including the physician, nurse, rehab, activities, and dietician. The unit manager stated that medication lists are not routinely printed out, and new prescriptions are provided to residents on paper. The social worker confirmed that all sections of the discharge planning tool should be completed before the resident or responsible party receives the paperwork. The Director of Nursing acknowledged the concern when informed of the incomplete documentation, and no additional documentation related to the resident's discharge was provided.