Failure to Complete Discharge Summaries and Provide Bed Hold Notices
Penalty
Summary
The facility failed to complete a discharge summary for one resident who was reviewed for discharge planning. Specifically, the medical record for this resident, who had diagnoses including dementia and dysphasia and was admitted for a short-term stay, did not contain a completed discharge summary or discharge instructions. Although the resident's medications and belongings were reviewed and sent with the resident upon transfer to another LTC facility, the required discharge summary was not prepared or sent. Staff confirmed that they did not always complete the discharge summary or instructions as required. Additionally, the facility did not provide written bed hold notices to a resident who left on therapeutic leaves of absence. The medical record for this resident, who had diagnoses of congestive heart failure and cirrhosis and was independent with activities of daily living, showed multiple instances of leaves of absence without documentation that a bed hold was offered. Staff in social services stated they were not aware of the requirement to provide bed hold notices for therapeutic leaves and did not provide them to residents.