Failure to Document Valid Discharge Reasons and Physician Orders
Penalty
Summary
The facility failed to ensure that there was a valid reason for discharge and that a physician's discharge order was documented for four residents who were discharged. For each of these residents, the medical records lacked documentation of a physician's order for discharge and did not specify a valid reason for the discharge prior to the residents being transferred to other facilities. The records also did not show that the discharges were based on endangerment to the safety or health of the residents or others, as required. Instead, the discharges were attributed to the facility's decision to remodel a locked unit, with no evidence of immediate medical necessity or resident-specific justification. The residents involved had significant cognitive impairments and complex medical histories, including diagnoses such as vascular dementia, Alzheimer's disease, delusional disorders, mood disorders, epilepsy, and chronic kidney disease. Care plans for these residents indicated risks such as elopement, wandering, depression, and the need for supervision with activities of daily living. Despite these vulnerabilities, the facility did not document individualized discharge planning or ensure that the residents or their responsible parties were given adequate notice or choice regarding the transfer. Family members reported being informed of the transfer on the same day it occurred, with some stating they were not given options for alternative facilities or provided with discharge paperwork or instructions. Interviews with facility staff, including the DON, ADON, and administrator, revealed inconsistencies and gaps in the discharge process. Staff were unclear about the required notice period for discharges, the documentation needed, and the involvement of the physician in initiating discharges. The facility's discharge policy required that discharges be appropriate and documented in the medical record, but this was not followed. The lack of proper documentation and communication placed residents at risk for diminished continuity of care and unsafe or improper discharges.