Failure to Complete Physician Discharge Summary
Penalty
Summary
The facility failed to ensure that a discharge summary was completed by the physician for one resident. The clinical record review of a resident revealed that the resident was admitted to the facility and later expired and was discharged. However, there was no documented evidence in the resident's clinical record that a discharge summary was completed by the physician upon the resident's death and discharge. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the required documentation.
Plan Of Correction
The facility cannot retroactively correct the presence of a physician discharge summary on resident 63. Residents who discharged in the last 30 days will be reviewed to determine the presence of a physician discharge summary. Nursing staff and physicians will be re-educated on completion of a discharge summary. Audits will be completed on residents who discharge to ensure completion of a discharge summary by the physician weekly x 4 weeks, then monthly x 2 months. Findings will be reviewed at monthly QAPI meeting.