Failure to Obtain Physician Orders for Resident Discharges
Penalty
Summary
The deficiency involves the facility’s failure to obtain required physician discharge orders for two residents prior to their discharge. For one resident admitted with a thoracic vertebra fracture, urinary tract infection, and muscle weakness, review of the admission MDS dated 12/11/25 showed these diagnoses remained current, and facility documents showed the resident was discharged on a later date; however, the most recent physician orders contained no order authorizing discharge. For a second resident admitted with atrial fibrillation, diabetes mellitus, and protein-calorie malnutrition, review of the 5-day MDS dated 3/2/26 indicated the diagnoses remained current, and facility documents showed this resident was also discharged on a later date, again without any corresponding physician discharge order in the clinical record. During an interview on 3/18/26 at 1:45 p.m., the Director of Nursing confirmed that there were no physician orders for these discharges as required under 28 Pa. Code 211.12(d)(1)(5) for nursing services. These findings were based on review of clinical records, MDS assessments, facility-provided discharge documentation, and staff interview, which together demonstrated that the facility discharged two of three reviewed residents without documented physician authorization for discharge.
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.