Incomplete Discharge Documentation and Instructions
Penalty
Summary
The facility failed to provide comprehensive discharge instructions and did not ensure that documentation of a resident's discharge was present in the medical record. Specifically, a resident with multiple diagnoses, including cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease, hypertension, hyperlipidemia, heart failure, gastro-esophageal reflux disease, hyperkalemia, and insomnia, was discharged to their home. Review of the multidisciplinary discharge summary showed that discharge instructions were incomplete, with no evidence of education regarding diet or activities provided to the resident or their representative. Additionally, there was no documentation of a discharge note for the resident's discharge on the specified date. The Director of Nursing confirmed the incomplete documentation during an interview.