Failure to Notify Legal Guardian and Incomplete Medication Reconciliation at Discharge
Penalty
Summary
Facility staff failed to provide written notice to a court-appointed legal guardian prior to or at the time of a resident’s discharge to a group home, and failed to accurately complete medication reconciliation on the discharge summary. The resident had multiple significant diagnoses, including muscle wasting/atrophy, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, insomnia, affective mood disorder, compulsive sexual behaviors, atherosclerotic heart disease, cerebral infarction, and vitamin and magnesium deficiencies. The MDS documented moderately impaired cognitive skills, need for set-up/touch assistance with ADLs, and occasional incontinence, and Section Q indicated the resident did not want to be asked about returning to the community. The clinical record also contained a court order adjudicating the resident incapacitated and appointing a guardian with authority over all decisions, including living arrangements and placement. The resident’s clinical record documented a discharge to a group home, but there was no documented involvement, consent, or notification of the legal guardian regarding this discharge. There was no documented basis or rationale from a physician or other provider for the discharge to a lower level of care, no documented discharge plan, and no documented request from either the resident or the guardian to leave the facility. Social services notes referenced discussions with the resident and the group home and identified a planned discharge date, later postponed by one day, but did not document any notification to the guardian. The discharge summary listed the group home address and included the guardian’s name and phone number, yet contained no evidence that the guardian was notified or provided written notice of the discharge, including reasons, anticipated date, or destination. The discharge summary stated that pre- and post-discharge medications had been reconciled, but it did not list all medications that were to be continued after discharge. Specifically, aspirin, atorvastatin, ferrous sulfate, spironolactone, and Trulicity were omitted from the discharge medication list, despite a nurse practitioner note indicating these medications were to be continued for treatment of cerebral infarction, hyperlipidemia, vitamin deficiency, congestive heart failure, and diabetes. It was unclear from the record whether the resident, the resident’s representative, or the receiving provider received copies of the discharge instructions. Interviews with the guardian confirmed she was unaware of the discharge until notified by a hospital social worker after the resident was found in the community, and interviews with facility staff confirmed there was no written letter or documented written notice to the guardian, and no documented discharge plan beyond the discharge summary.
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