P4880

Missing Physician Discharge Summaries for Discharged Residents

Drums, Pennsylvania Survey Completed on 01-16-2025

Penalty

No penalty information released

Summary

The facility failed to ensure that a discharge summary, including the physician's final diagnosis and prognosis or cause of death, was completed for three discharged residents. This deficiency was identified during a review of closed clinical records and confirmed through a staff interview. Specifically, the records of three residents who were either discharged or expired at the facility lacked the required physician's discharge summary.

Resident 35 was admitted to the facility and expired there, yet their record did not contain a discharge summary with the final diagnosis and cause of death. Similarly, Resident 187, who was discharged from the facility, and Resident 34, who was also discharged, both had records missing the physician's discharge summary with the final diagnosis and prognosis. The Director of Nursing confirmed the absence of these summaries during an interview.

Plan Of Correction

1. Residents 34, 35 and 187 had physician discharge summaries completed.

2. A 30 day look back was completed and physician discharge summaries were completed.

3. The DON was re-educated on ensuring physician discharge summaries are completed on discharge. The Administrative Assistant will complete discharge chart audits to ensure completion.

4. The NHA or designee will conduct an audit of discharged resident charts weekly x 4 weeks then monthly x 2 months to ensure completion of the physician discharge summary. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.