Failure to Complete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to complete discharge summaries for two residents who were permanently discharged, as required by policy. For one resident, the electronic medical record (EMR) did not contain a discharge summary or a progress note indicating the resident's discharge, despite documentation that the resident was a respite admission under hospice status and was discharged to home or community. The Minimum Data Set (MDS) assessment confirmed the discharge, but the necessary summary and documentation were missing from the record. For the second resident, who had severe cognitive impairment and multiple diagnoses including diabetes, hypertension, and dementia, the nursing progress note indicated discharge with family and hospice assistance, and that medications and a comfort kit were provided. However, the EMR did not contain a discharge summary for this resident either. The MDS assessment confirmed the discharge, but the required summary was not present in the electronic chart. Interviews with facility staff, including the social worker, DON, and administrator, confirmed that the discharge summaries were not completed for these residents. The social worker, who had recently started, was unable to explain the omissions, and the DON acknowledged that the facility had been without a full-time social worker for several months. Facility policy requires an interdisciplinary discharge summary to be completed and included in the closed medical record for all permanent discharges, but this was not done for the two residents in question.