Failure to Provide Written Discharge Notification and Complete Discharge Documentation
Penalty
Summary
The facility failed to provide a resident with a written notification of discharge and did not complete a recapitulation of the resident's stay as required. The resident, who had a history of frequent falls and cerebral infarction, was admitted with intact cognition and required maximal assistance with bathing and dressing, but was independent with ambulation. The resident's goal was to discharge back into the community, and an active discharge plan was documented. However, the electronic medical record lacked both a baseline and comprehensive care plan. Physician orders indicated discharge from physical therapy and a potential discharge home, and a progress note documented the resident leaving the facility with family members. Interviews with nursing staff revealed confusion and inconsistency regarding who was responsible for completing discharge paperwork. It was confirmed that the recapitulation of stay and discharge summary were not completed in the electronic medical record, and the facility did not provide or have the resident or responsible party sign any discharge paperwork. The facility's policy required informing residents or their representatives about discharge policies and documenting discharge planning and arrangements, but this was not followed in the resident's case.