Failure to Document and Complete Appropriate Resident Discharge
Penalty
Summary
The facility failed to provide evidence of an appropriate discharge for a resident, including the completion of a discharge summary or recapitulation of stay, and did not document the details of the discharge in the medical record. The resident, who had multiple diagnoses such as osteomyelitis of vertebrae, asthma, substance abuse, anxiety, bipolar disorder, hypertension, depression, and muscle weakness, was cognitively intact at the time of discharge. The discharge was executed with less than 30 days' notice, citing an emergency due to alleged endangerment of safety in the facility. The discharge location was a local hotel, and the discharge notice was not signed by the resident or facility staff. Review of the facility's investigation revealed a lack of written statements from residents or staff, with the only evidence being hearsay reported by the Administrator. The resident denied the allegations of illicit drug distribution. There was no documentation in the medical record regarding the need for immediate discharge, no discharge summary, and no signed physician's order for the discharge. A verbal order was claimed to have been received but was not signed by the medical director. The facility's policy required a discharge order and a summary of information to ensure continuity of care, but these steps were not followed in this case.