Failure to Provide Complete Discharge Information and Documentation
Penalty
Summary
The facility failed to provide required discharge information and documentation to a resident at the time of discharge. Resident G, who had diagnoses including hemiparesis and hemiplegia following a cerebrovascular accident and chronic obstructive pulmonary disease, was admitted on an unspecified date and discharged on 2/14/26. A psychosocial note dated 2/11/26 documented that the resident was notified their last covered day would be 2/13/26, but there were no additional notes regarding the resident actually being discharged or what discharge instructions were provided. A Discharge Planning Review dated 2/14/26 was signed by the resident, but only the first two sections were completed; the remaining sections, including medications and follow-up visits, were left blank. During interviews, the Social Service Director stated the resident was discharged home and that a home health referral had been made, but there was no documentation of this referral in the resident’s record, only an email related to the referral. The Director of Nursing stated that at discharge, residents should receive a discharge summary, a list of medications, any equipment orders, and there should be a progress note in the record, but such documentation was not present for this resident. The facility’s “Discharge summary” policy required that when discharge is anticipated, the resident must have a discharge summary including a recapitulation of the stay and reconciliation of pre-discharge and post-discharge medications, which was not fully completed or documented for Resident G.
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