Failure to Complete Discharge Summaries Timely
Penalty
Summary
The facility failed to ensure that a physician's discharge summary was completed within 30 days of discharge for two residents. Resident 167, who expired on December 12, 2024, did not have a discharge summary completed by the physician within the required timeframe. Similarly, Resident 168, who was discharged home on November 19, 2024, also lacked a timely discharge summary. This deficiency was confirmed during an interview with the Director of Nursing on January 31, 2025, at 12:30 p.m., who acknowledged that the discharge summaries for both residents were not completed within the mandated 30-day period.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. The NHA/designee educated physicians on timely completion of discharge summaries. The Medical Records Director/designee will audit discharged residents' charts to ensure a discharge summary is completed within 30 days of discharge by the physician. Audits will be done weekly x 4 weeks then monthly thereafter. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.