Failure to Obtain Physician Discharge Order and Complete Post-Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident’s discharge was ordered and assessed by a physician in accordance with its transfer/discharge policy. The facility’s policy required the physician to document medical reasons for transfer or discharge in the medical record for any reason other than nonpayment or facility closure, and to attach a copy of the physician’s discharge order to the discharge notice. For community discharges, the policy also required preparation of a discharge summary and plan of care. The resident, who had been admitted on an earlier date and had a history and physical dated 6/8/25 indicating capacity to understand and make decisions, received a Notice of Proposed Transfer and Discharge dated 1/27/26. The notice cited that the resident’s health had improved sufficiently so that facility services were no longer required and that the resident had failed, after reasonable and appropriate notice, to pay, and it identified the name and address of the board and care facility to which the resident was to be discharged. Despite this, review of the resident’s Order Summary Report dated 2/27/26 showed no physician’s order for discharge. The Post Discharge Plan of Care and Summary report dated 1/7/26 contained incomplete documentation from nursing and social services. Further review of the last two physician progress notes dated 2/3/26 and 2/13/26 did not show documentation that the resident’s health status had improved or that the resident was deemed safe for discharge. During an interview and concurrent record review on 3/3/26, an RN confirmed that a physician’s order is required for discharge and that the Post Discharge Plan of Care and Summary must be completed by the IDT prior to discharge, and verified that the resident did not have a discharge order and that the post-discharge documentation was incomplete. The Administrator was informed of and acknowledged these findings.
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