Failure to Complete Timely Discharge Summaries
Penalty
Summary
The facility failed to complete discharge summaries within the required 30 days for two residents, as evidenced by a review of closed clinical records and interviews with facility staff. Resident R164 was admitted on December 9, 2024, and discharged on December 18, 2024, but the discharge summary was not completed within the mandated timeframe. Similarly, Resident R162, admitted on November 26, 2013, and discharged to the hospital on January 13, 2025, also lacked a timely discharge summary. Interviews with the Nursing Home Administrator confirmed these findings, indicating a lapse in adherence to the facility's policy on discharge documentation.
Plan Of Correction
1. R164 is discharged and record closed. R162 is discharged and record closed. 2. All discharges from March 20 will be audited to ensure 30 day discharge note from attending physician has been completed. 3. Education to all attendings that a discharge summary must be completed within 30 days completed. 4. Random audits by the Administrator/designee of up to 5 residents to ensure that the attending has completed a 30 days discharge note once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.