Failure to Complete and Document Resident Discharge Summaries and Notifications
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for the safe and orderly transfer or discharge of two residents. For one resident, the discharge summary was incomplete, lacking essential information such as a recapitulation of the stay, physical assessment, discharge instructions, and signatures from the resident, their representative, or transportation service. Additionally, there was no documentation in the electronic medical record regarding the resident's discharge on the day it occurred, including details about the mode of transportation, diet, discharge vitals or assessment, or education provided. For the second resident, the discharge summary was also incomplete, with the recapitulation of the stay left blank and no signature from the resident or their representative. The summary only indicated that the resident was discharged home with a family member, without further required details. Interviews with staff confirmed that discharge summaries and progress notes were expected to be completed by the interdisciplinary team (IDT) and provided to the resident, their family, or the receiving facility, but this process was not followed for these residents. Furthermore, the administrator acknowledged that the ombudsman was not notified of the residents' discharges, despite being aware of the regulatory requirement to do so. The facility's policy requires comprehensive documentation and communication during transfers or discharges, including providing necessary information to the receiving provider and appropriate notifications, but these steps were not completed as required for the two residents involved.