Failure to Provide Proper Discharge Documentation and Planning
Penalty
Summary
The facility failed to properly discharge a resident by not providing all necessary information and documentation required for a safe and effective transition of care. The resident, who had significant medical and cognitive impairments including vascular dementia, major depressive disorder, type 2 diabetes with neuropathy, and bilateral below-knee amputations, was not his own responsible party. The facility issued a discharge notice for non-payment but did not document a discharge summary, discharge plan, or provide adequate notification to the resident, responsible party, or ombudsman. The discharge notice also lacked a specific address for the resident's discharge destination. Record review showed no evidence of discharge planning discussions or documentation in the nursing progress notes. Interviews with facility staff revealed that the discharge process was still ongoing, with no finalized plan or summary in place. The ombudsman and responsible party were not properly informed, and there was confusion among staff regarding the resident's discharge status and destination. The resident expressed concerns about not receiving sufficient help with his Medicaid application and uncertainty about his ability to return home, while the responsible party indicated the resident's previous home was uninhabitable and that family support was unavailable. Facility policy requires documentation of the basis for discharge and a plan to ensure a safe transition, but these steps were not followed. The lack of a documented discharge summary, plan, and proper notification could compromise the resident's continuity of care and transition to an appropriate setting, as the facility had not determined a safe discharge location or communicated effectively with all involved parties.