Failure to Document and Communicate Required Discharge Information
Penalty
Summary
The facility failed to ensure that resident medical records contained all required discharge information and that appropriate information was communicated to the receiving facility for two residents reviewed for discharge planning. For one resident with diagnoses including aftercare following major joint replacement, dementia, and osteoarthritis, the medical record lacked documentation indicating the resident was being discharged or specifying the receiving facility. Additionally, a scheduled follow-up medical appointment was not communicated to the receiving facility, resulting in a missed appointment. The discharge summary only generically referenced transfer to another nursing home, and the resident signed the summary without clear documentation of the discharge plan. For another resident with chronic obstructive pulmonary disorder, sleep apnea, and diabetes, the medical record similarly lacked documentation regarding the discharge or the destination facility. The discharge summary again only referenced transfer to an unnamed nursing home. Interviews with the Administrator and DON revealed that during a period of social worker turnover, discharge planning responsibilities were shared among staff, leading to gaps in documentation and communication. The facility's discharge policy required providing an appropriate summary of information at discharge, which was not met in these cases.