Failure to Communicate Accurate Discharge Information and Orders
Penalty
Summary
The facility failed to ensure that appropriate and accurate information was communicated to a resident's family and home health provider upon discharge. A resident with severe cognitive impairment, multiple medical diagnoses, and a newly developed stage II sacral pressure ulcer was discharged back to her group home. The discharge summary provided to the family and home health case manager incorrectly stated that the resident had no skin impairment and did not include the current physician's order for wound care. Additionally, the discharge medication list omitted the wound care order that was in place at the time of discharge. The home health agency did not receive confirmation of the resident's discharge until several days after the actual discharge date, and the necessary physician orders were not printed by the agency until even later. As a result, the initial home health nursing visit occurred after a delay, during which time the resident's wound had increased in size. Interviews with facility and home health staff confirmed the lack of timely and accurate communication regarding the resident's discharge status and care needs, in contradiction to the facility's own discharge planning policy.