Failure to Document Discharge Planning and Required Notifications
Penalty
Summary
The facility failed to document discharge planning for a resident who was admitted with multiple diagnoses, including chronic obstructive pulmonary disease, atherosclerotic heart disease, anxiety disorder, hypertension, osteoarthritis, and depression. The resident was admitted for a short-term stay and expressed a desire to return home safely, as reflected in her care plan. Despite a 30-day discharge notice being issued due to non-payment and a physician's order for discharge to home with hospice care, there was no documentation in the progress notes regarding the resident's discharge. Additionally, the recapitulation of stay form was incomplete, with only the sections on mobility and activities of daily living filled out, and no nursing discharge note was present in the medical record. Interviews with facility staff confirmed that required documentation was missing. The Assistant Director of Nursing acknowledged that a nursing discharge note and a fully completed recapitulation of stay form should have been present. The Administrator confirmed the resident was discharged to her sister's home but was unsure about the discharge planning process. The former Social Worker stated she was not present at the time of discharge and was uncertain about the arrangements made for home health care and therapy, as she was no longer employed at the facility when the discharge occurred.