Failure to Provide Discharge Instructions and Prescriptions at Time of Discharge
Penalty
Summary
The facility failed to provide a resident with discharge instructions and prescription medication at the time of discharge. The resident was admitted with multiple diagnoses, including cervical disc degeneration, lumbar radiculopathy, hemiplegia, end stage renal disease, muscle wasting/atrophy, difficulty in walking, need for assistance with personal care, chronic diastolic condition, and thrombocytopenia. The admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact. Facility policy required completion of discharge transition instructions for residents anticipating discharge to a private residence or similar setting to assist with a safe adjustment to their living environment. Clinical record review showed that on the day before discharge, the social worker communicated with the resident’s family about referrals for potential facility-to-facility transfers and, when no transfer was secured and Medicare benefits were exhausted, the facility planned discharge home with skilled home care referrals and a post-discharge primary care appointment. Transportation was arranged for the morning of the discharge date. A progress note documented that the resident was discharged to home, first going to dialysis and then home, and that all personal belongings remained at the facility awaiting family pickup and receipt of discharge instructions and prescriptions. The discharge summary, signed later that day by an RN, listed several medications with specific dosing schedules and times for the next doses, but there was no indication that these instructions or prescriptions were provided to the resident at the time of discharge. In an interview, the RN who signed the discharge summary confirmed that the resident had already left the facility when she signed the discharge packet around 9:00 p.m., and therefore she could not provide the packet to the resident. She stated that the usual practice is to complete the discharge before any scheduled appointment and to ensure the resident leaves with discharge instructions, prescriptions, and belongings, which did not occur in this case. The RN also confirmed she was not the nurse who discharged the resident and that discharge instructions were not provided at the time of discharge. The administrator confirmed that the resident was alert and oriented and should have received discharge instructions and prescription medication upon discharge, and that there was no documentation that the discharge summary and prescription information were offered or refused. The resident’s representative did not pick up the discharge instructions and prescription documentation until later that evening, confirming that the resident had been discharged without these materials, in violation of state regulatory requirements cited in the report.
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