Failure to Provide Safe Discharge Planning and Documentation
Penalty
Summary
The facility failed to ensure proper preparations were made for a safe discharge for one resident who left the facility against medical advice. According to the facility's policy, nursing services and/or social services are responsible for obtaining discharge orders, arranging recommended services and equipment, preparing medications for discharge, and providing the resident or representative with required documents such as a discharge summary and plan. However, review of the resident's electronic health record showed that no discharge instructions or discharge summary were completed at the time of discharge. Interviews with facility staff confirmed that discharge instructions and summaries are typically completed in the electronic health record, but in this case, none were present. Additionally, no arrangements for home health services or equipment needs were made prior to the resident's departure. The lack of discharge planning and documentation was only identified after the surveyor brought it to the facility's attention.