Failure to Document Discharge Summaries for Two Residents
Summary
The facility failed to document a discharge summary for two residents, leading to a deficiency in communication of necessary information at the time of discharge. Resident #98, who had multiple diagnoses including Type 2 Diabetes Mellitus with foot ulcer and Alzheimer's Disease, was transferred to a behavioral health hospital due to behaviors and safety concerns. Despite being discharged from the behavioral hospital to another facility, no discharge summary was completed. Interviews with the social worker, Director of Nursing (DON), Assistant Administrator, and Administrator confirmed the absence of a discharge summary for Resident #98. Similarly, Resident #99, who had diagnoses including Anxiety Disorders, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, was discharged without a documented discharge summary. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The DON and Administrator confirmed that a discharge summary should have been completed but was not present in the resident's medical record. This lack of documentation for both residents indicates a failure in the facility's discharge process.
Penalty
A resident with chronic pain was discharged with an inaccurate written discharge summary stating a 30-day supply of Oxycodone, while only a seven-and-a-half-day supply was provided. Interviews with the Regional Nurse and DON confirmed the discrepancy as a clerical error, contrary to the facility's policy on medication reconciliation.
A resident was discharged from an LTC facility without a complete discharge summary, missing key information such as admission and discharge details, treatment, and progress. The resident, who had a behavior agreement due to non-compliance with facility rules, was discharged for smoking marijuana. Interviews revealed no documentation of a discharge notice being provided, contrary to the facility's policy.
A facility failed to complete a discharge summary for a resident discharged home, missing key components such as a recapitalization of the stay, a final summary of status, and a post-discharge plan. The resident, with multiple diagnoses and severe cognitive impairment, required assistance with ADLs. An LPN confirmed the absence of the discharge summary, which was against the facility's policy requiring the interdisciplinary team to complete it.
A facility failed to provide a comprehensive discharge summary for a resident with a complex medical history, omitting a recapitulation of the resident's stay as required by policy. The discharge instructions only included physician orders and medications, lacking a detailed summary of the resident's medical history and care received.
A facility failed to complete a discharge summary for a resident upon discharge or transfer. The resident had multiple diagnoses, including a displaced fracture and diabetes. A review revealed no discharge summary, instructions, or progress note in the medical record. The Administrator confirmed the lack of documentation, stating the family initiated the discharge.
The facility failed to complete discharge summaries for two residents, one with schizoaffective disorder and another with metabolic encephalopathy, upon their discharge home. Despite the facility's policy requiring comprehensive discharge documentation, including a summary of stay and post-discharge plan of care, these were not completed. The absence of these documents was confirmed by the Social Service Designee and the Director of Nursing.
Inaccurate Discharge Summary for Resident's Medication
Penalty
Summary
The facility failed to ensure that the written discharge summary for Resident #65 accurately reflected the amount of Oxycodone provided at the time of discharge. Resident #65, who had diagnoses including paraplegia, chronic pain syndrome, and major depression, was discharged with a care plan that included medication management for chronic pain. A physician order indicated that the resident was to receive Oxycodone 20 mg four times a day. However, the discharge summary inaccurately stated that the resident would receive a 30-day supply of medication, while only 30 tablets of Oxycodone, equating to a seven-and-a-half-day supply, were actually provided. Interviews with the Regional Nurse and the Director of Nursing confirmed the discrepancy between the discharge summary and the actual amount of medication given. The Regional Nurse acknowledged the error as clerical, and the Director of Nursing confirmed that the discharge instructions inaccurately documented a 30-day supply of medications. The facility's policy on transfer and discharge required reconciliation of all pre-discharge medications, which was not accurately followed in this case. This deficiency was investigated under Master Complaint Number OH000163758.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a resident's discharge summary included a comprehensive recapitulation of the resident's stay. This deficiency affected a resident who was admitted with diagnoses including major depressive disorder, acquired absence of both legs below the knee, schizoaffective disorder, and constipation. The resident was discharged to another long-term care facility without a complete discharge summary. The summary lacked critical information such as the resident's admission date, reason for admission, reason for discharge, treatment provided, progress in the facility, nutritional information, and therapy services. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that the resident had a behavior agreement due to non-compliance with facility and CDC recommendations, which included not leaving the facility without supervision. The resident was discharged for smoking marijuana in the facility, but there was no documentation of a discharge notice being provided to the resident. The facility's discharge policy requires a detailed summary of the resident's stay, which was not adhered to in this case.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for Resident #39, who was discharged home. The medical record review and staff interview revealed that the discharge summary was missing essential components, including a recapitalization of the resident's stay, a final summary of the resident's status, and a post-discharge plan. Resident #39 had been admitted with diagnoses such as chronic kidney disease, sick sinus syndrome, hypertension, osteoarthritis, and traumatic subdural hemorrhage. The Minimum Data Set (MDS) assessment indicated that the resident was severely cognitively impaired and required assistance with activities of daily living. Despite these needs, the discharge summary was not completed, as confirmed by an interview with an LPN. The facility's policy required the interdisciplinary team to complete the discharge summary, including medication reconciliation and a post-discharge care plan, which was not adhered to in this case.
Failure to Provide Comprehensive Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of a resident's stay, affecting one resident who was discharged to their home. The resident had a complex medical history, including conditions such as traumatic subdural hemorrhage, rhabdomyolysis, diabetes mellitus, and hypertension, among others. Upon review, it was found that the discharge instructions provided to the resident did not include a recapitulation of the resident's stay, which is a requirement according to the facility's policy. The discharge instructions only included physician orders and a list of medications, without a comprehensive summary of the resident's medical history and care received during their stay. The facility's policy mandates that a discharge summary should include a detailed recapitulation of the resident's stay, including diagnoses, medical history, treatment, and current status at the time of discharge. However, the medical record review revealed no documented evidence of such a summary for the resident in question. An interview with the Social Service Director confirmed the absence of a discharge summary that included a recapitulation of the resident's stay, indicating a lapse in adherence to the facility's discharge policy.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident upon discharge or transfer. This deficiency was identified during a closed record review and interview, affecting one of two residents reviewed for discharge. The resident in question was admitted with multiple diagnoses, including a displaced fracture, hypertension, atrial fibrillation, and diabetes, among others. Upon discharge, there was no evidence in the medical record of a discharge summary, discharge instructions, or a progress note indicating the resident's discharge or transfer. An interview with the Administrator confirmed the absence of necessary documentation, noting that the family had initiated the discharge or transfer process.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that discharge summaries were completed for two residents, Resident #47 and Resident #51, as required by their policy. Resident #51 was admitted with multiple diagnoses including schizoaffective disorder and anxiety disorder, and was discharged home with her husband after completing rehabilitation services. However, there was no evidence of a discharge summary, post-discharge plan of care, or discharge instructions in her medical record. The Social Service Designee confirmed the absence of these documents, attributing it to her inexperience in the position. Similarly, Resident #47, who had diagnoses such as metabolic encephalopathy and type two diabetes, was discharged home after short-term rehabilitation. Despite the care plan indicating a need for a discharge summary, none was found in the resident's medical record. The Director of Nursing confirmed the lack of a discharge summary after reviewing the records. The facility's policy required a comprehensive discharge summary, including a summary of stay, medication reconciliation, and a post-discharge plan of care, none of which were completed for these residents.
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