Missing Required Discharge Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure that required documentation for discharge was present in the medical record for one resident. The resident, who had paraplegia and a local skin infection, was admitted with intact cognition. During the resident's stay, a conflict of interest arose when the nurse practitioner (NP) recognized the resident as being involved in a lawsuit with the NP. The resident agreed to be transferred to another facility due to this conflict. Upon review, it was found that there was no physician or provider order indicating the basis for the resident's discharge, no discharge summary, and no notice of discharge in the resident's medical record. Multiple staff interviews confirmed that these required documents were missing. The case manager, social services director, assistant director of nursing, medical records director, and administrator all acknowledged the absence of the necessary discharge documentation. Facility policy required that a physician or provider's order be obtained for all discharges, that a discharge summary be completed, and that a notice of proposed discharge be provided to the resident and documented in the medical record. Despite these requirements, none of these steps were completed for the resident in question, resulting in a lack of proper documentation and communication regarding the discharge.