Failure to Document Resident Discharge and Communicate Transfer Information
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure proper documentation and communication regarding the transfer or discharge of a resident. Specifically, for one resident with multiple complex diagnoses, including COPD, hypertension, bipolar disorder, chronic kidney disease, atrial fibrillation, and several fractures, the medical record did not contain documentation of the date, time, or events related to the discharge. Additionally, there was no discharge summary present in the resident's file. The facility census did not reflect the resident's presence, and during an interview, the Assistant Director of Nursing confirmed that the required discharge note was missing and acknowledged that the resident had been transferred to another nursing home.