Failure to Ensure Safe and Documented Discharge Process
Penalty
Summary
The facility failed to ensure that a resident's transfer or discharge was conducted in accordance with required documentation and procedures, as outlined in both regulatory requirements and the facility's own policy. Specifically, the resident was discharged without a physician's documentation in the medical record to support a safe and effective transition of care. There was no evidence of a discharge planning meeting, no 30-day discharge notice issued, and no documentation that the Ombudsman was notified, as required. Multiple staff interviews confirmed the absence of these critical steps, and the resident's medical record lacked the necessary discharge summary and post-discharge plan of care. The resident in question had a history of alcohol dependence with withdrawal, depression, and weakness, and was noted to have severe cognitive impairment based on a BIMS score of 6. The care plan identified behavioral issues related to alcohol use and non-compliance with facility rules, including bringing alcohol into the building and smoking in his room. Despite these complex needs, the discharge process did not include an interdisciplinary team meeting or a comprehensive assessment of the resident's ongoing care needs, as required by the facility's discharge planning policy. The resident, who was his own responsible party, was reportedly agreeable to the move, but there was no documentation of a formal discharge plan or physician involvement in the process. Interviews with facility staff, including the previous Administrator, DON, RCN, and LVN, revealed inconsistent recollections regarding the discharge process. Some staff believed the resident left voluntarily, while others acknowledged that the required documentation and notifications were not completed. The physician did not recall signing a discharge notice or participating in a discharge planning meeting. The facility's policy mandates a thorough discharge planning process, including assessment, interdisciplinary planning, and documentation, none of which were evident in this case. The lack of proper discharge procedures and documentation could compromise the resident's safety and continuity of care.