Failure to Document and Communicate Discharge Information
Penalty
Summary
The provider failed to follow its own policy to ensure that a resident's discharge plan was properly documented and that appropriate information was communicated to the receiving nursing home. Specifically, there was no documentation to support that any referral information or discharge planning communication was sent to the facility that accepted the resident for admission. The resident's closed electronic medical record lacked progress notes indicating communication with the receiving facility, and the required Instruction and Summary for Discharge assessment was incomplete. Key sections of the assessment, such as the summary of the resident's status and rehabilitative services, were either not completed or unsigned, and the medical provider's signature was missing. The resident involved had multiple care needs at the time of discharge, including a Foley catheter, recent signs and symptoms of a possible urinary tract infection with pending lab results, a physician's order for continuous oxygen, use of a wheelchair cushion and low-air-loss mattress, and a recent course of Vancomycin for C. difficile. The documentation failed to include important resident-specific information such as recent COVID testing results, nurse assessments for COVID-19 symptoms, and updated wound care information. The absence of a social services designee at the time of discharge meant that no other staff member was identified to assume responsibility for discharge planning, resulting in incomplete and insufficient information being provided to the receiving facility.