Failure to Document Physician Orders for Resident Discharges After Altercation
Penalty
Summary
The facility failed to ensure that two residents who were discharged following a resident-to-resident altercation had the required physician documentation in their medical records to support a safe and effective transition of care. Both residents were involved in a physical incident, after which immediate discharge notices were issued. However, there was no timely physician progress note in the electronic medical record (EMR) documenting the basis for the discharges at the time they occurred. Instead, late entries were made by the physician nearly two months after the discharges, backdating the effective date to coincide with the original discharge dates. Resident #1 was a cognitively intact male with a history of seizures, dementia, epilepsy, congestive heart failure, mood disorder, and chronic obstructive pulmonary disease. He was discharged to another facility following the altercation, but the required physician documentation was not present in the EMR at the time of discharge. Similarly, Resident #2, also cognitively intact and with a history of cerebral infarction, dementia, hemiplegia, major depressive disorder, and anxiety disorder, was discharged to a hospital without the necessary physician documentation in the EMR. Both residents' care plans noted behavioral issues, and both were involved in the incident that led to their discharges. Interviews with facility staff, including the DON, administrator, and physician, confirmed that the physician was aware of the discharges but did not document the clinical justification in the EMR at the time of the events. The physician acknowledged the oversight and stated she was unaware of the requirement to document the reason for discharge in the medical record. Family members of both residents reported that they were not informed about the appeal process for the discharges, and both residents experienced emotional distress following their removal from the facility.