Failure to Complete and Provide Discharge Instructions at Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a Discharge Instruction was completed and provided to a resident upon discharge, which is necessary for a safe and effective transition of care. The process for completing the Discharge Assessment involved multiple departments, with the Social Services Director completing initial sections and nursing staff responsible for the remaining sections, including medications, diet/nutrition, ADL/bowel & bladder/restorative nursing, education/appointments, and skin condition on discharge. However, upon review, it was found that only the initial sections were completed, and the critical nursing sections remained incomplete. The Discharge Instruction was not printed, signed by the resident or responsible party, or provided at the time of discharge. Interviews with facility staff revealed that the nurse responsible for discharging the resident did not remember completing or providing the Discharge Instruction, and there was no reminder system in place to ensure completion. The Medical Records/Transportation staff confirmed that the discharge paper was not uploaded to the electronic health record, as it was never placed in the scan box by nursing. The facility's process required the nurse to print and provide the completed Discharge Assessment for the resident or family to sign, but this step was missed, resulting in the absence of documentation and notification regarding the resident's needs post-discharge. The affected resident had significant medical conditions, including hemiplegia, hemiparesis, sequelae of cerebral infarction, and morbid obesity. The resident's care plan indicated a desire to be discharged home with family and required written instructions to ensure continuity of care. The incomplete Discharge Instruction meant that essential information regarding medications, follow-up appointments, diet, and other care needs was not communicated to the resident or family, as required by facility policy and procedure.