Failure to Accurately Document Change in Discharge Plan and Appeal
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident in accordance with accepted professional standards. Facility investigative documentation for a facility-reported incident showed that a resident, who was his/her own decision maker, left the facility in the early morning hours without informing staff and later returned home safely. Review of records also showed that the resident had been given a notice of non-coverage indicating the last covered day of the stay and the right to appeal, and the resident signed this notice. Further review of the resident’s medical record revealed a Social Services progress note documenting that the Social Services Assistant received the last covered day notice and that the resident was ready to go home and planned to discharge earlier than originally indicated, with home health to be set up and the resident planning to go home by taxi. In a subsequent interview, the Social Services Assistant stated that after providing the notice, she contacted a family member involved in the resident’s care, who expressed a desire to appeal the discharge and felt the resident needed more time. The Social Services Assistant reported that she informed staff there would be an appeal and that the resident would be staying, and she later told the resident about the family member’s wish for the resident to remain. She confirmed that she did not document this updated discharge plan and appeal information in the resident’s medical record, resulting in an incomplete and inaccurate record for the resident.
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