Failure to Complete and Communicate Required Discharge Documentation
Penalty
Summary
Surveyors identified a failure to ensure that discharge information was documented in the medical record and appropriately communicated to the receiving provider for one resident. The resident was an older female with multiple significant diagnoses, including cerebral infarction with right-sided hemiplegia, dysphagia, hyperlipidemia, Buerger's disease, psychotic disorder, and major depressive disorder. Her MDS showed short- and long-term memory deficits, modified independence in decision-making, inattention, disorganized thinking, verbal behaviors, and dependence in most ADLs with a mechanically altered diet. Her care plan included DNR status, behavior issues such as yelling and cursing at staff, refusal of psychiatric treatment and incontinent care, use of bedside loops, anticoagulant use, contractures, foot drop, and an existing skin impairment. Record review showed that, despite this complex clinical profile, the resident’s EMR contained no physician’s order to discharge, no Interdisciplinary Team discharge plan, and no completed discharge summary. The care plan had a closing date, but there was no documentation of the required discharge elements such as the practitioner’s contact information, advance directive information, special instructions or precautions for ongoing care, or comprehensive care plan goals being included in the discharge documentation. The DON reported that the discharge nurse only completed a progress note indicating the resident was transferred via ambulance with medications and personal belongings, without documenting the receiving location or whether a report was called and clinical records were sent. Interviews with LVNs and the DON revealed that staff understood, in general terms, that discharges should include a face sheet, medication list, pertinent labs, recent physician documentation, and a discharge assessment or transfer form, and that a nurse-to-nurse report should be called to the receiving facility. However, for this resident, the DON confirmed that neither a transfer form nor a discharge assessment and discharge summary were completed, and there was no documentation that current physician’s orders, care plan, psychiatric notes, or a history and physical were sent to the accepting facility. The facility’s own policy required that specific information, including practitioner contact information, resident representation and advance directive information, special instructions or precautions, comprehensive care plan goals, and all necessary clinical information, be conveyed to the receiving provider, but this was not documented for the resident’s discharge to another nursing facility of her choice.
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