Incomplete Discharge Documentation and Medication Review for a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and complete discharge process for one resident. The resident had multiple complex diagnoses, including rhabdomyolysis, moderate protein-calorie malnutrition, hypertensive chronic kidney disease stage V, seizures, hypothyroidism, anemia, hyperfunction of the pituitary gland, urinary retention, hyperlipidemia, diabetes insipidus, and hypopituitarism. A discharge MDS assessment showed the resident had cognitive impairment and required setup or cleanup assistance for ADLs. On the day of discharge to home via private car, progress notes documented that family was present, gathered belongings, and discharge paperwork was given. However, the nursing section of the discharge documents completed by the LPN responsible for the discharge was not filled out. Review of the medical record and interviews revealed there was no evidence that discharge medications were reviewed or offered to the resident or family, and the discharge paperwork was incomplete. The Ombudsman reported that the resident was discharged without medication prescriptions and that the discharge paperwork was not filled out completely. The DON confirmed that the discharge documentation was incomplete and that there was no evidence discharge medications were reviewed or offered. The LPN who discharged the resident acknowledged she did not complete the discharge paperwork and did not document reviewing discharge medications or offering a three-day supply, despite this being required by facility policy. The facility’s Transfer and Discharge policy specified that the nurse caring for the resident at the time of discharge must ensure the Discharge Summary is complete, including a recap of the stay, final status, and reconciliation of pre- and post-discharge medications, which was not done in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.