F0628

D

Failure to Provide and Document Written Discharge Instructions at Time of Discharge

Estherville, Iowa Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that discharge instructions were documented in the medical record and provided in written form to a resident and/or the resident’s representative at the time of discharge. The resident had an MDS showing intact cognition (BIMS 14), independence with ADLs using a walker, and diagnoses including cerebrovascular accident, hemiplegia, anxiety, depression, and schizophrenia. The care plan and multiple care conference notes documented an ongoing goal and discussions about the resident’s wish to return home, with family expressing that discharge home remained a possibility and later anticipating a return home in the spring. On 2/24, a provider order was received for discharge home on 2/28, and the resident was discharged that day.

Following discharge, the resident’s family reported that no discharge instructions or orders were reviewed or given to the resident or family when they arrived to take the resident home, stating they simply packed belongings and left. The Administrator confirmed the family had called to arrange discharge home, and the DON stated she went over discharge instructions with the resident prior to discharge but acknowledged that the discharge instructions were not signed by the resident. The DON further confirmed that discharge instructions were mailed to the resident several days after discharge for signature and had not been returned. Staff A, an RN, stated that no discharge paperwork was given to the resident or family at the time of discharge. This sequence of events occurred despite a facility policy stating that residents will receive proper written notice consistent with federal regulations and that discharge planning must include documentation of all planning activities.