Failure to Document and Notify Properly During Resident Transfers and Discharges
Penalty
Summary
The facility failed to appropriately document and notify regarding the transfer and discharge of two residents. For one resident, the Minimum Data Set (MDS) indicated a discharge to a short-term general hospital, but nursing progress notes and discharge instructions showed the resident was actually discharged to an assisted living facility with his son. The discharge documentation was incomplete, lacking the reason for discharge, destination, resident or representative signature, and home care agency information. There was also no discharge summary or recap of stay in the electronic medical record (EMR). Staff interviews confirmed discrepancies in the documentation and confusion about the resident's actual discharge location. For the second resident, the MDS indicated the resident died in the facility, but EMR review and staff interviews revealed the resident was transferred to a hospital by EMS and died there. There was no documentation in the EMR to show the resident left the facility or was accompanied by EMS, and no physician orders for discharge or transfer were present. A bed hold request was documented, but no transfer forms were found. The facility did not have formal policies for admissions, transfers, and discharges, relying instead on standards of practice and outdated training materials.