Failure to Document Social Services Discharge Planning Communications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting the communications and actions taken by social services regarding the resident's discharge planning. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and major depressive disorder, expressed a desire to be transferred to a location closer to family. The resident reported that discussions about discharge planning with facility staff had occurred weeks prior, and was open to various locations near her desired area. During interviews and record reviews, the Social Services Director confirmed ongoing communication with contacts at potential receiving facilities and discussions with the resident about discharge options. However, there was no documentation in the resident's medical record reflecting these communications or actions. The Director of Nursing also confirmed the absence of any progress notes or records of discharge planning discussions in the electronic medical record. This lack of documentation was not in accordance with the facility's own policies and procedures, which require all services and progress toward care plan goals to be documented.