Failure to Document and Notify Resident of Discharge and Appeal Rights
Penalty
Summary
The facility failed to ensure proper documentation and notification during the discharge process of a resident who was sent to the hospital for a change in condition and subsequently not readmitted. The resident, who was cognitively intact and had complex medical needs including a stage 4 pressure ulcer, neurogenic bladder and bowel, and quadriplegia, was discharged without a 30-day discharge notice, discharge orders, or a discharge summary present in the electronic medical record (EMR) at the time of review. The facility only provided a discharge order and summary after the surveyor requested it, and these documents were dated several weeks after the actual discharge event. Interviews with facility staff revealed that the decision not to readmit the resident was based on concerns about non-compliance with care, suspected drug use, and perceived safety risks to other residents. The administrator, DON, and social worker all supported the decision not to allow the resident to return, citing issues such as missed wound care appointments, non-compliance with repositioning, and reports of drug use and paraphernalia. However, the physician was not aware of the discharge at the time it occurred, and the DON admitted to not realizing that proper discharge documentation had not been completed. The facility's own policy required that residents and/or responsible parties be notified prior to transfer or discharge, and that discharge documentation, including physician orders and a discharge summary, be present in the clinical software. These requirements were not met in this case, as there was no evidence of a 30-day discharge notice or timely discharge documentation in the resident's EMR. The lack of proper documentation and notification could affect residents who are sent to the hospital for a change in condition and are not readmitted.