Failure to Provide Discharge Summaries and Plans of Care for Discharged Residents
Penalty
Summary
The facility failed to complete and provide discharge summaries and discharge plans of care for four residents who were discharged to home. Each resident's medical record lacked the required documentation summarizing their course of stay, therapy services received, and a post-discharge plan of care. Although transfer/discharge reports and progress notes indicated that residents were discharged and that some discharge instructions were given, there was no comprehensive discharge summary or plan of care included in the records or provided to the residents or their representatives. The residents involved had varying degrees of cognitive impairment and multiple medical diagnoses, including anemia, hypertension, renal failure, diabetes, heart failure, and recent orthopedic surgeries. All had received occupational and physical therapy services during their stay. Documentation reviewed showed that while some therapy notes and home evaluations were completed, these were not attached to the medical records or given to the residents or their families at discharge. In some cases, discharge instructions were noted as given and understood, but there was no indication of who received them or if all necessary information was provided. Interviews with facility staff, including the DON and ADON, confirmed that the facility did not provide discharge summaries or plans of care to residents at the time of discharge. The facility's own policy required a discharge summary and post-discharge plan of care for residents discharged to home or another care setting, detailing the resident's status, care needs, and education provided. However, this process was not followed, resulting in incomplete documentation and lack of required information for discharged residents.