F0628

D

Failure to Document Required Discharge Notifications and Summary

Brandon, Florida Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The facility failed to complete and document required discharge and transfer notifications, including the reason for discharge, for one resident. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, other acute osteomyelitis of the left ankle and foot, COPD, and muscle weakness, and was later discharged. Review of the electronic medical record showed no documentation of the required discharge elements per facility policy, including the AHCA discharge/transfer form, discharge notifications, or the reason for discharge. There was also no documented discharge summary or evidence of a post-discharge plan of care.

During interviews, the Social Services Director stated they had only worked at the facility for one week, did not know the resident, and were unaware of any discharge appeal. After reviewing the record, the Social Services Director confirmed there was no documentation of an appeal, no AHCA discharge/transfer form, and no discharge summary. The Nursing Home Administrator stated that social services is responsible for discussing discharge with residents, conducting an assessment, documenting notes related to discharge, notifying residents at least two days before discharge, and documenting a meeting about the discharge plan. The Nursing Home Administrator acknowledged that there was nothing in the record related to the discharge and explained that the facility did not have a dedicated social services staff member at the time and that coverage staff were not completing the required discharge documentation correctly. Review of the facility’s Discharge Planning policy confirmed that a discharge summary and post-discharge plan of care are required but were not present in this case.