Failure to Reconcile Medications in Discharge Summary
Penalty
Summary
The facility failed to provide a comprehensive discharge summary for Resident CR82, which is a requirement under §483.21(c)(2). Specifically, the discharge summary did not include a reconciliation of all pre-discharge medications with the resident's post-discharge medications. This omission was identified during a review of the clinical record and confirmed by the Regional Clinical Consultant. The resident, who was admitted on 10/05/24, had a medical history that included osteoarthritis of the left knee, pancytopenia, a history of falling, and aortic valve stenosis. The resident was discharged to home on 10/31/24, but the necessary medication reconciliation was not documented in the discharge summary. The facility's policy, dated 11/01/24, mandates that a discharge summary be provided to the receiving care provider at the time of discharge. However, for Resident CR82, this policy was not adhered to, as evidenced by the lack of documentation in the clinical record. The deficiency was confirmed during an interview with the Regional Clinical Consultant, who acknowledged the absence of the required medication reconciliation in the discharge summary.
Plan Of Correction
For residents CR82, a discharge summary was completed. All residents of the facility for the last 30 days will be reviewed, and a discharge summary will be completed. Licensed staff will be educated on discharge summary and the reconciliation of medications at the time of discharge and disposition of medications by the Director of Nursing/Designee. An audit will be completed by the Director of Nursing/Designee for all residents who are being discharged from the facility prior to the resident being discharged to ensure that the resident's clinical record contains a discharge summary that includes a reconciliation of the resident's post-discharge medications. The audit will be weekly for 4 weeks, then monthly ongoing. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.