Failure to Provide and Document Safe Discharge Planning
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident prior to discharge, as required by policy. A resident with diagnoses including aftercare following hip replacement, PTSD, and osteoarthritis, who was cognitively intact, informed the nurse practitioner of their intent to leave against medical advice. The NP documented that the resident was safe and medically cleared for discharge, but there was no evidence of a physician's order for discharge, an interdisciplinary discharge plan, a notice of discharge, a discharge summary, or a medication reconciliation in the resident's record. Staff interviews confirmed that the unit nurse did not complete any discharge planning, discharge summary, or medication reconciliation for the resident. The Assistant Director of Nursing Services also could not provide evidence that the resident received an appropriate discharge. The resident reported leaving the facility with a friend and not receiving any paperwork, medications, or referrals to home care services. These actions and omissions resulted in a lack of documented and coordinated discharge planning for the resident.