Failure to Document and Prepare Safe Resident Discharges
Penalty
Summary
The facility failed to ensure proper documentation and preparation for the discharge of two residents, as required by its own policies and regulatory standards. For both residents, there was no documentation in the medical record specifying the basis for their discharge, nor evidence that written discharge instructions were provided to or discussed with the residents or their responsible parties. Additionally, there was no documentation of discharge planning that addressed caregiver support or referrals to local contact agencies, despite the facility's policy requiring such actions. One resident, admitted with multiple complex diagnoses including a right tibia fracture, MRSA infection, diabetes, and a history of venous thrombosis, was noted to have intact cognition and expressed a desire to return home. The resident's insurance coverage ended, and although the resident was informed of the option to pay out of pocket, this discussion and the resident's refusal were not documented. The discharge form was only partially completed, and there was no record of medication reconciliation, discharge instructions, or coordination of care in the resident's file. The second resident, admitted for short-term therapy following a stroke and with diagnoses including Alzheimer's disease and hemiplegia, also had no documentation in the medical record regarding the reason for discharge or any instructions about medications provided at discharge. Progress notes indicated the resident was discharged home with medications and that a follow-up evaluation was planned, but there was no evidence of written instructions or comprehensive discharge planning. Interviews with facility staff confirmed that required documentation and discharge procedures were not completed for either resident.