Missing Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to ensure the completion of a discharge summary for a resident, identified as CR72, who was discharged from the facility. Resident CR72 was admitted on 3/12/24 with diagnoses including dementia, prostate cancer, and high blood pressure. On 10/08/24, the resident's spouse informed the facility that Resident CR72 would not be returning. However, upon review of the closed clinical record, it was found that there was no discharge summary documenting the resident's stay and course of treatment. This deficiency was confirmed during an interview with the Regional Nurse Consultant on 12/05/24.
Plan Of Correction
1. Resident R72's discharge summary was opened and completed. 2. The last 10 closed charts will be audited for discharge summaries. All closed charts will be reviewed going forward to ensure discharge summary is in the closed file. 3. Nursing Home Administrator or designee will educate Interdisciplinary Team, which includes medical records, on discharge summaries to ensure that staff understands they have to be completed on all discharged residents and in the file prior to closing. 4. Nursing Home Administrator or designee will audit to ensure discharge summaries are included in closed charts. Audits will be completed on all discharged residents for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is met.