F0842

D

Failure to Document Hospital Discharge Communication in Resident Medical Record

Lancaster, California Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The facility failed to maintain an accurate and complete medical record for one of three sampled residents by not documenting a key communication regarding the resident’s potential return from a general acute care hospital. The resident had been admitted with diagnoses including unspecified parkinsonism, aphasia, and generalized muscle weakness, and had documented fluctuating capacity to understand and make decisions, with an MDS indicating moderately impaired cognitive skills for daily decisions. On the day in question, the Admissions Assistant (AA) spoke with the hospital Case Manager (CM) about the resident’s discharge back to the facility and informed the CM that the facility would accept the resident once candida auris test results were received so that appropriate isolation room arrangements could be made.

During interviews and record review, surveyors found no documentation of this conversation in the resident’s progress notes for that date. The AA acknowledged that the discussion with the CM was not documented and stated she had time to document it before leaving the facility but did not do so. The Assistant Director of Nursing (ADON) reported having no knowledge of whether the resident was returning and stated that the AA should have documented the conversation to ensure timely communication among departments and to maintain an accurate and complete medical record. Review of the facility’s Charting and Documentation policy with the Director of Nursing (DON) showed that all services and changes in a resident’s condition must be documented, and that documentation must be objective, complete, and accurate to facilitate communication among the IDT, underscoring that the missing entry was inconsistent with facility policy.