Failure to Timely Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary within the required 30 days following the death of a resident. Specifically, the clinical record of a resident who was admitted on June 28, 2021, and died on November 13, 2024, was reviewed. It was found that the discharge summary was not completed until January 31, 2025, which exceeded the 30-day requirement. This deficiency was confirmed during an interview with the facility's Nursing Home Administrator on January 31, 2025.
Plan Of Correction
Step 1 Discharge Summary for resident R200 was completed. Step 2 The facility completed an audit of discharge records for the last 30 days to ensure that a discharge summary was completed. Step 3 Medical record staff and physician educated on the requirement to ensure that a discharge summary is completed within 30 days of discharge. Step 4 Medical record Director/designee will audit discharged records weekly x 4 monthly x 2 to ensure that a discharge summary was completed. Findings will be reviewed during QAPI.