Failure to Document Basis for Discharge and Follow Discharge Procedures
Penalty
Summary
The facility failed to ensure that the basis for discharge was documented in the medical record for a resident who was discharged following an incident involving inappropriate behavior. The resident, who was cognitively intact and had no prior history of behavioral issues, was discharged after allegedly inappropriately touching another resident. There was no documentation in the clinical record regarding the basis for the discharge, nor was there a physician or nurse practitioner order for the discharge. The resident's care plan and progress notes did not reflect any consideration of the caregiver's ability to provide care post-discharge, and there were no discharge notes from the social worker. Interviews with facility staff revealed that the decision to discharge the resident was made jointly by the Administrator and the DON, who instructed the ADON to contact the resident's family member for immediate pick-up. The family member was not provided with discharge instructions, documents, or asked to sign any paperwork, and was not contacted by the facility after the discharge. The ombudsman was not notified of the discharge, and the social worker did not provide post-discharge resources or document the discharge in the medical record. Facility policy requires that the basis for transfer or discharge be documented in the resident's medical record and that appropriate information be communicated to the receiving party. Staff interviews confirmed that the facility did not follow its own discharge policy and procedures, including obtaining a physician's order, notifying the ombudsman, and documenting the basis for discharge. The lack of documentation and communication placed the resident at risk for an improper and unsafe discharge.