Failure to Obtain Hospital Discharge Summary and Inconsistent Leave of Absence Procedures
Penalty
Summary
The facility failed to obtain a hospital discharge summary in a timely manner after a resident was readmitted following a fall and hospital transfer. The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, returned to the facility without any hospital discharge paperwork. Despite facility policy requiring review of discharge paperwork within 24 hours of return, staff did not request or obtain the necessary documentation from the hospital. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the discharge summary was not obtained or reviewed, and there was no documentation explaining why this was not done. Additionally, the facility did not act promptly when the same resident failed to return from a Leave of Absence (LOA) at the expected time. The resident left the facility with a planned return time but did not come back as scheduled. Nursing notes indicated that the resident was still out nearly three hours after the expected return, and further documentation showed the resident was absent for almost ten hours before being returned by a Good Samaritan. Although the DNS stated that staff attempted to contact the resident's responsible party and local hospitals, there was no documentation of these efforts, and required notifications to the DNS, Administrator, local police, and physician were not completed as directed by facility policy. The investigation also revealed confusion and inconsistency regarding the facility's LOA policies. Multiple versions of the LOA policy were in circulation, with conflicting instructions on the steps staff should take when a resident does not return as expected. Staff had electronic access to a more recent policy, but the DNS and Administrator stated that an older policy was the one in use, as confirmed by corporate leadership. This lack of clarity resulted in staff not having clear, unified guidance on how to respond to residents who do not return from LOA in a timely manner.