Incomplete Discharge Summary for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide a comprehensive discharge summary for a resident, identified as Resident CR1, who was discharged to home with home health services. The discharge summary, dated January 6, 2025, lacked critical information about the resident's medical condition during their stay, specifically omitting details about a Stage 3 Pressure Ulcer on the sacrum. The documentation inaccurately stated that there was no wound care or treatment, despite previous records indicating the presence of a significant wound requiring attention. This deficiency was identified through a closed clinical record review and staff interview, revealing that the discharge summary did not include a full recapitulation of the resident's stay, including diagnoses, course of illness, treatment, therapy, and pertinent consultation results. The omission of this vital information was discussed with the Nursing Home Administrator on March 7, 2025, highlighting the facility's failure to meet the regulatory requirements for discharge summaries.
Plan Of Correction
1. Resident CR1 was not harmed. 2. The Director of Nursing reviewed discharged residents for the last two months to ensure necessary components were documented on the discharge summaries. 3. The Director of Nursing educated the RN supervisors of the importance of including all essential elements on the discharge summary, specifically emphasizing the need to document any wound care treatments provided during their care at the facility. 4. The Director of Nursing will audit discharge summaries weekly for four weeks, then monthly for three months to ensure essential elements, specifically any wound treatments are indicated on the discharge summary.