Failure to Complete Discharge Recapitulation and Provide Complete Involuntary Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to complete a discharge summary with a recapitulation of the resident’s stay, including medication reconciliation, and failure to issue a fully compliant involuntary discharge notice. The resident had schizoaffective disorder and borderline intellectual functioning, with an admission MDS showing intact cognition (BIMS 15), no depression, and verbal behaviors toward others. The MDS indicated no plans for discharge and that the resident planned to remain at the facility. A Cognitive Loss/Dementia CAA identified potential for altered cognitive patterns related to schizoaffective disorder and noted verbal behaviors, but the electronic health record lacked evidence that a comprehensive care plan was developed for this resident. An involuntary discharge notice was issued, citing that the safety of individuals in the facility was endangered due to the resident’s behaviors, including an incident in which the resident engaged in actions that posed an immediate and serious risk of fire requiring staff intervention. The notice referenced ongoing explosive, aggressive, and unsafe behaviors and specified a discharge date 30 days from the notice, as well as discharge locations and appeal rights. However, the notice did not include information on how to file an appeal or identify who in the facility would assist the resident with the appeal. It also omitted the Ombudsman’s name and email contact information, and lacked contact information for the State Agency responsible for protection and advocacy for individuals with developmental disabilities and for individuals with a mental disorder. The resident’s physician orders did not contain a discharge order, and there was no recapitulation of the resident’s stay or documented medication reconciliation at the time of discharge, despite facility policy requiring a discharge summary that includes a recapitulation of the stay. Progress notes documented that the resident was to receive an involuntary discharge and be discharged with 30 days of medications, and that the family was educated to call 911 if aggression occurred. Another progress note documented that the resident was discharged home with family with medications and belongings, and a subsequent note indicated the family returned seeking clarification on how to administer the medications. During interviews, staff and a consultant confirmed that administrative staff prepared discharge paperwork, that no narcotics were sent with residents, and that no recapitulation or medication list could be produced for what was sent with the resident at discharge, confirming the lack of required discharge documentation and complete notice content.
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