Failure to Obtain and Document Physician Order Prior to Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a physician’s order prior to discharging a resident. The resident was admitted with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side, dysphagia, acute kidney failure, and major depressive disorder. On admission, staff assessed the resident’s cognitive skills for daily decision making as moderately impaired, and at discharge they were assessed as severely impaired. Progress notes documented that the resident was discharged home with a family member, but the physician’s orders did not contain an order authorizing discharge, and the resident’s care plan did not include discharge goals or objectives. A Discharge Planning Review form, which was undated, indicated the resident was discharged home due to insurance, noted that the resident would not have a caregiver after discharge, and that no home services were in place. Surveyor review of the EHR did not show a discharge order in the physician’s order list or order tab. A physician’s order for discharge with home health services, dated as a verbal order on the day of discharge, was not entered into the EHR until months later, with a printed date corresponding to the survey. The ADON stated that residents who discharge require a discharge summary, physician’s orders indicating the resident is able to discharge, and a recapitulation of the stay, and acknowledged being asked by the Interim DON to enter the discharge order on the survey date, while being unsure whether the physician had actually given an order at the time of discharge. The Interim DON reported that a physician’s order was received the day of discharge but confirmed it was only entered into the EHR on the survey date. An LPN stated that everything related to a resident, including discharge, requires a physician’s order and that the order tab is the only place in the system where such orders can be found, and confirmed that the discharge order for this resident was created the day before his interview. The facility’s Transfer and Discharge policy, last revised in June 2020, states that residents are transferred or discharged upon a physician’s order and that the clinical record must contain physician documentation supporting the necessity of the transfer or discharge.
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