Failure to Timely Document Discharge Coordination in Medical Record
Penalty
Summary
The facility failed to ensure that documentation regarding the coordination of care during the discharge process was entered into the medical record in a timely manner for one resident. The resident, who had diagnoses including Parkinsonism and End Stage Renal Disease, was discharged to an assisted living facility and required transportation to dialysis. Although the case manager communicated the resident's needs to the receiving facility via email and text message, this communication was not documented in the resident's electronic health record at the time of discharge. The case manager acknowledged that all relevant information was kept in personal emails and text messages rather than being properly charted in the resident's medical record. A review of the records showed that the case manager's progress note documenting the coordination of care was created and signed several weeks after the resident's discharge. The facility's policy required that details of transfers or discharges be documented in the medical record and communicated to the receiving provider. The DON confirmed that documentation should have been entered into the resident's record and stated that, despite the late entry, the expectation was for timely documentation of such communications.