Incomplete Discharge Documentation and Notification
Penalty
Summary
A deficiency occurred when the facility failed to provide a complete written discharge summary and a list of medications to a resident upon discharge. The resident, who had diagnoses including nontraumatic subacute subdural hemorrhage, COPD, type 2 diabetes, repeated falls, and mobility issues, was readmitted to the facility and later discharged home. The discharge summary form in the medical record was incomplete, with several sections left blank, including skin evaluation, treatments, cognitive/psychosocial status, ADLs, sensory, dietary, rehabilitation services, and education/acknowledgement. The section for instructions after discharge was only partially completed, and the medication list, pharmacy details, and documentation of scripts provided were not addressed. There was no evidence that the discharge summary was given to the resident or signed by either the resident or staff, nor was there documentation of medication reconciliation or confirmation that medications were provided upon discharge. Interviews with facility staff revealed a lack of documentation and communication regarding the discharge process. The resident's sister, who was listed as the health care surrogate and POA, reported she was not notified in advance of the discharge and only received a call after the resident had left. Staff interviews indicated that the discharge was not planned according to standard procedures, and there were no progress notes or documentation of discharge planning or education provided to the resident. The Social Services Assistant and DON confirmed that the discharge summary was incomplete and not signed, and that the physician order for discharge and referral to home health were not completed until the day after the resident left. Attempts to contact the nurses and CNAs who worked during the discharge period were unsuccessful, and there was no documentation in the progress notes regarding the discharge. The facility's policy required an effective discharge process, including preparation of residents for transition and provision of necessary documentation. However, the process was not followed in this case, as evidenced by the incomplete discharge summary, lack of medication documentation, and absence of communication with the resident's designated representative. The discharge occurred without proper planning, documentation, or notification, resulting in a failure to meet regulatory requirements for resident discharge.