Failure to Complete Discharge Summary Within 30 Days
Penalty
Summary
The facility failed to complete a discharge summary within 30 days of a resident's death, as required by regulation. A closed clinical record review for a resident revealed that nursing documentation noted the resident was without pulse or respirations and was pronounced deceased. However, the review also showed that no discharge summary, including the final diagnosis and cause of death, was completed within the required timeframe. This deficiency was identified during a closed clinical record review and confirmed through staff interviews.
Plan Of Correction
1. Facility cannot retroactively provide resident 100's discharge summary. 2. Medical records director/designee conducted an audit of the last 2 weeks of discharges to verify discharge summaries have been completed. 3. Providers will be re-educated on providing discharge summaries. 4. DON/designee will audit discharges to verify they have completed discharge summaries weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.