Alta Rehab At Fairmont

in a ‘scan' box to be uploaded to the system. V15 stated if he (R5) was discharged on 08/14/2025 then she (V15) should have uploaded the discharge paper already because she checks the scan box every other day. On 09/03/2025 at 10:23am, V15 (Medical Records/Transportation) stated she was not able to find the discharge paper for (R5).

That she looked at the scan box and there is no document to upload. V15 stated it means the nurse did not print the discharge instruction for him to sign. On 09/03/2025 at 10:51am, V26 (RN-Registered Nurse/Night Shift Supervisor) stated the facility has Discharge Assessment on the ‘Assessment' tab in EHR system.

The nurse, who will discharge the resident, is expected to complete the Discharge Assessment in EHR system.

The night shift nurse assigned to the resident is responsible for completing the Medications Section of the Discharge Assessment.

The nurse, who is discharging the resident, should print the completed Discharge Assessment because there is a section on the Discharge Assessment where the resident has to sign.

Signing the Discharge Assessment is an acknowledgment that the resident or the POA receives the medication and the discharge instruction.

Each section of the Discharge Assessment will turn green once completed. If it did not turn green, it means that section is not completed or answered yet.

Discharge Assessment should be completed prior to discharge. A complete Discharge Assessment gives instruction to the resident or family how they will take the medication and the purpose of the medication. It also explains the follow up appointments that are scheduled. If not completed and not given to the resident, the resident may miss the appointments and or may not take the medications appropriately. R5's admission Record documented that R5's diagnoses (include but not limited to) hemiplegia and hemiparesis, sequelae of cerebral infarction, and morbid obesity due to excess calorie. R5's Census list documented that R5 was readmitted on [DATE] and was discharged on 8/14/2025. R5's (06/30/2025) care plan documented, in part I wish to be discharged home w/family.

Will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date.

The resident needs written instructions, as required, to ensure care continuity post-discharge.

R5's (08/10/2025) Discharge Instruction documented, in part discharge date and time: 08/14/2025 11:00(am). Of note, Sections A and B were completed by V7 (Social Services Director).

Sections C.

Medications, Section D.

Diet/Nutrition - Dietary, Section E. ADL/Bowel & Bladder/Restorative Nursing, Section F.

Education/Appointments, Section G.

Skin Condition on Discharge & Treatments - Nursing were not completed.

Space provided for Name of Person Completing the Sections and Resident/Responsible Party Signature, as applicable, has no entry.The (09/04/2025) email correspondence with V28 (Regional Nurse Consultant) documented, in part Referring to the Discharge Instruction on the ‘Assessment' tab in EHR system.

What is the expectation? The expectation is for staff to complete prior to discharge and provide a copy upon discharge.

The (undated) Discharge/Transfer of Resident documented, in part Purpose: To provide safe departure from the facility. To provide for continuity of care and treatment.

Equipment: Discharge Notice.

Procedure: 1.

Explain discharge procedure to resident and family.

Provide additional health education or medication instruction information for resident or family as indicated in lay(man) terms. 7.

Complete Transfer Form Accurately and completely.

Rationale/Amplification.

Ensure that resident's current physical and psychosocial assessment, medications and current treatment is completely describe. 11.

Document discharge summary.

Include notes on specific instruction given (medications) to resident and responsible party in lay(man)'s terminology.

Facility ID: