Failure to Follow Late-Entry Documentation Policy for Discharge Communications
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and procedures for timely and accurate documentation in a resident’s medical record. The resident was admitted with multiple diagnoses, including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A History and Physical indicated the resident had capacity to understand and make decisions, while an MDS assessment documented moderately impaired cognition and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order directed discharge home with home health services. Following the resident’s discharge home, the State Survey Agency identified documentation that had been newly added to the resident’s record on the same date the surveyors were onsite. A social worker acknowledged entering a progress note on that date with an “effective date” several weeks earlier, describing a family discussion about concerns regarding the resident’s readiness for discharge and the family’s decision to proceed with home discharge after declining alternative placement options. The social worker stated this was not the facility’s standard practice, admitted failing to document the interaction when it occurred, and expressed concern that the timing of the note’s creation coincided with the start of the State’s investigation. The note was not identified as a late entry as required by facility policy. The Assistant DON and DON both confirmed that staff did not document key discharge-related communications with the resident and family in a timely or policy-compliant manner. The Assistant DON stated that, per policy, late entries must be clearly identified as such, use the current date and time, and not give the appearance of having been written earlier, but acknowledged documenting a home visit and provision of discharge paperwork many days later without labeling it as a late entry. The DON stated that staff failed to timely document communication to the resident and family. The facility’s written policy on corrections, errors, omissions, and late entries requires that missed or delayed documentation be clearly identified as late entries or addenda, with current date and time and reference to the original incident, which was not followed in this case, resulting in an inaccurate account of the resident’s record.
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