Failure to Provide Required Discharge Documentation and Medication Reconciliation
Penalty
Summary
The facility failed to ensure that appropriate discharge documentation was present in the medical records for three residents. For each of these residents, the records were missing essential discharge summaries, a recapitulation of their stay, a final summary of their status, and a reconciliation of all pre-discharge and post-discharge medications, including both prescribed and over-the-counter drugs. The care plans for these residents did not indicate any discharge focus, goals, or interventions, and there was no evidence of a comprehensive discharge summary assessment being completed. One resident, who had significant medical needs including aftercare for surgical amputation, immunodeficiency, diabetes, and required assistance with most activities of daily living, was discharged without a documented discharge care plan or information about the home care agency providing follow-up services. Another resident, who was cognitively impaired and dependent on staff for daily care, was discharged with orders for home care services and a seven-day supply of medications, but the documentation lacked a full recapitulation of her stay, a final summary of her status, and a medication reconciliation. The resident's family also reported not receiving a discharge care plan or understanding the medication reconciliation process. A third resident, who was cognitively intact but dependent for daily care due to multiple chronic conditions, was discharged with home care services arranged, but the facility's records did not include a completed discharge summary. Interviews with facility staff revealed a lack of awareness regarding the requirements for discharge documentation and the absence of a streamlined discharge process. The facility's policy required comprehensive discharge summaries and individualized post-discharge plans, but these were not completed as required for the residents in question.