Lack of Required Physician Documentation for Involuntary Discharge
Penalty
Summary
The facility failed to ensure that a physician documented the required elements in the medical record to support an involuntary discharge of a resident. For one resident (R44) reviewed for discharge, the comprehensive electronic medical record did not contain a physician note documenting the basis for the discharge, the specific needs the resident had that could not be met in the facility, the attempts the facility made to meet those needs, and the services available at the receiving facility to meet those needs. An involuntary discharge notice dated 1/30/26 stated that the resident was being discharged due to being a threat to the personal safety of another resident (R23), but this notice was not supported by the required physician documentation in the medical record. During an interview on 3/12/26, the Administrator, with the DON/Regional Consultant present, confirmed that there was no physician note in the resident’s record addressing the basis for the discharge or the other required elements, and confirmed that the resident had been discharged and would not be returning. As of 3/13/26, the Administrator had not provided any evidence of such a physician note and stated that this was her first involuntary discharge and she was not aware of all of the requirements.
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