Failure to Provide Discharge Summary and Plan
Penalty
Summary
The facility failed to ensure that a discharge summary, including post-discharge medications and a post-discharge plan of care, was completed for a resident. This deficiency was identified during a review of clinical records and staff interviews. Specifically, for one of the three discharged residents reviewed, there was no documented evidence that the resident received discharge instructions that included post-discharge medications or a post-discharge plan of care. The deficiency was highlighted by a nursing note indicating that the resident was picked up by a transport company to be discharged to another facility. However, as of the day before the discharge, there was no documentation of the required discharge instructions. An interview with the Assistant Nursing Home Administrator confirmed the absence of this documentation, which is a violation of the regulatory requirements for discharge summaries.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Facility is unable to create the discharge summary for Resident #149. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit the last month of discharged residents to ensure the discharge summary was completed and make corrections if applicable/able. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff on how to properly complete a discharge summary. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of discharged residents to ensure the discharge summary was completed weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.