Failure to Complete Timely Therapy Discharge Summaries
Penalty
Summary
The facility failed to maintain timely and accurate medical records for two residents by not completing required discharge summaries for physical therapy (PT) and occupational therapy (OT) services. For one resident with diagnoses including congestive heart failure and polyarthritis, the last PT and OT treatment notes were completed in early January, but no discharge summaries were documented after therapy services ended. Interviews with the therapy manager confirmed that discharge summaries should have been completed at the time of discharge, as they provide essential information on the resident's progress, current level of function, and recommendations for ongoing care. Another resident, admitted with conditions such as anoxic brain damage, hemiplegia, and monoplegia, also did not have a PT discharge summary completed after the last PT treatment. The physical therapist confirmed that the resident was discharged from PT, but the required summary was not documented. The absence of these summaries meant that other staff were not formally informed of the residents' therapy discharge status or the recommendations for their continued care. Facility policy required all documentation to be completed within 48 hours of service provided or attempted. The failure to complete these discharge summaries for both residents was identified through record review and staff interviews, demonstrating a lack of adherence to the facility's documentation standards and professional requirements for maintaining accurate and timely medical records.