Missing Discharge Summary for Deceased Resident
Penalty
Summary
The facility failed to ensure the completion of a discharge summary, including the physician's final diagnosis and cause of death, for a resident who had been discharged. Specifically, the clinical record of a resident who was admitted on January 26, 2018, and expired on November 9, 2024, did not contain the required physician's discharge summary. This deficiency was identified during a review of the resident's closed clinical record on December 12, 2024. An interview with the facility administrator on the same day confirmed the absence of the necessary documentation.
Plan Of Correction
1. Physician discharge summary note placed note for Resident 35. 2. Re-education to all physicians and physician extenders on importance of placing discharge summary note within 30 days of resident discharge from the facility. 3. A 6-month (June 2024- December 2024) lookback of discharged residents was completed to ensure timely discharge note was placed. 4. DON/Designee will complete audit of discharged residents and physician note entry monthly x 3 and reported to QAPI.