Failure to Provide Required Discharge Documentation for Multiple Residents
Penalty
Summary
The facility failed to provide proper discharge documentation for three out of four residents reviewed for discharge. In the case of one resident who was transferred to an assisted living facility, the discharge process was delayed by one to two weeks due to incomplete and unclear documentation, lack of coordination, and missing information in the discharge summary. The required sections of the discharge summary, such as care during stay, recapitulation of illness and treatment, functional status, and pre-discharge preparation, were not completed. The social services director, who was responsible for the discharge, did not document key aspects of the process and was reportedly unsure about the necessary procedures and the receiving facility. Another resident, who was discharged home, also did not receive a complete discharge summary. The documentation provided at discharge consisted only of an order summary with an active medication list, lacking details such as the date and time of last medication administration and a comprehensive recap of the resident's stay. The care plan did not address discharge planning, and the interdisciplinary discharge summary was left incomplete. The social worker, who was primarily responsible for discharge planning, was not available, and the director of nursing confirmed that the documentation was insufficient and incomplete. A third resident was transferred to a hospital, but the facility failed to document the transfer appropriately or communicate necessary information to the receiving provider. There was no completed discharge summary, no documentation of the reason for transfer, and no bed-hold notice or explanation regarding the resident's potential return. The progress notes did not address the discharge, and the interdisciplinary discharge summary remained unfinished. The director of nursing acknowledged the lack of documentation and information regarding the resident's transfer.