Failure to Provide Wheelchair and Proper Discharge Documentation
Penalty
Summary
A quadriplegic resident, who required a wheelchair for primary mobility due to spastic quadriplegic cerebral palsy, was discharged and transferred to an Adult Services Residential Program facility in Pennsylvania without being provided with a wheelchair. Interviews with staff revealed that although there was discussion about sending a manual wheelchair with the resident, there was no documentation confirming that a wheelchair was actually sent. The receiving facility reported that the resident arrived without any wheelchair, manual or electric, which was his main mode of locomotion. Additionally, the facility failed to document the transfer and discharge of the resident in the medical record. There was no discharge progress note on the day of discharge, and essential information such as a summary of the resident's stay, education on medications and treatments, a list of belongings, details of who picked up the resident, and the reason for discharge were missing. All discharge documentation was handled through email and TEAMS meetings rather than being properly recorded in the medical record as per facility policy.