Failure to Obtain Discharge Order and Provide Comprehensive Discharge Summary
Penalty
Summary
Facility staff failed to obtain a physician's discharge order and did not provide a comprehensive discharge summary for a resident who was discharged to the community. The resident's medical record lacked documentation of a discharge order from the attending physician, and there was no evidence that a discharge summary, including a summary of the resident's stay, diagnosis, course of illness, treatment, therapy, pertinent lab and radiology results, pending lab results, special instructions for ongoing care, post-discharge plan of care, advance directive information, and medication reconciliation, was provided to the resident or their representative. Additionally, there was no signed copy of the discharge summary or post-discharge plan by the resident or their representative in the medical record. Interviews with staff revealed that the discharge process was initiated on the day of discharge, but staff were unaware of any follow-up resources being set up, such as home health services. The administrator confirmed that the facility's expectation was for the Social Services Director to arrange necessary resources and communicate them to the resident or representative, with documentation in the medical record. However, the administrator acknowledged that there was not a single form containing all required discharge information and confirmed the absence of a physician's discharge order in the resident's electronic medical record.