Lack of Physician Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that the physician documented the clinical rationale for the discharge of a resident who had been admitted with diagnoses including spinal fusion and depression. Record review showed that, as of June 1, the resident was recommended for follow-up imaging and was noted to benefit from continued care. Despite this, a Notice of Proposed Transfer/Discharge was issued, and subsequent documentation did not provide clinical justification that the resident no longer required facility services or that discharge was in the best interest of the resident's health and safety. Progress notes later stated the resident was independent and cleared for discharge, but lacked supporting clinical rationale from the physician. Interviews with facility staff, including the Social Service Director, Nurse Practitioner, and Director of Nursing, confirmed that discharge planning began with a physician order, but the medical record did not reflect the necessary assessment or documentation supporting discharge readiness. The facility's policy required that the basis for transfer or discharge be documented in the resident's clinical record by the attending physician, which was not done in this case.