Failure to Provide Required Discharge Documentation and Notification
Penalty
Summary
The facility failed to provide the required discharge documentation and notifications for a resident diagnosed with Alzheimer's disease who was taken home by her son. Medical record review showed that the resident's son expressed his intention to take his mother home, and staff informed him that he would need to sign against medical advice (AMA) documents. However, there was no documentation in the progress notes confirming that AMA documents were signed, nor was there evidence that a discharge summary or other required discharge information was provided to the resident or her family. Additionally, there was no record of the facility attempting to have the resident or her family sign any AMA documents. An interview with an LPN confirmed the absence of documentation supporting a safe and orderly discharge process for the resident. Review of the facility's transfer and discharge policy indicated that a discharge summary and post-discharge plan of care should be developed and reviewed with the resident and/or representative prior to discharge, and that nursing should document the discharge in the progress notes. These steps were not followed in this case, resulting in non-compliance with facility policy and regulatory requirements.