Failure to Complete Discharge Summaries and Recapitulation of Stay
Penalty
Summary
The facility failed to ensure the completion of discharge summaries, including a recapitulation of the resident's stay and final status at discharge, for three residents reviewed for discharge. For each of these residents, documentation was incomplete or missing, with key sections such as nursing services, physical function status, assistive devices, therapy plans, medication disposition, and skin condition left unaddressed. In some cases, discharge instruction forms were missing essential information such as dietary recommendations, skin condition, patient education, and required signatures. For one resident, the discharge instruction form was dated after the actual discharge date and lacked details in several sections, including dietary, skin, and patient education. The recapitulation of stay form was also incomplete, and no discharge note or summary was found in the medical chart. The family member reported that while medications were sent home, no paperwork or follow-up information was provided at discharge, and the only paperwork received was from a prior hospital stay. For the other two residents, similar deficiencies were observed. One resident's discharge instruction form was incomplete, and the recapitulation of stay document only included vitals and weight, with no comprehensive summary. Interviews with staff revealed that while there was an expectation for discharge summaries and recapitulations to be completed collaboratively by the interdisciplinary team, there was no process in place to ensure that all required information was completed and documented in the medical record. Facility policy required a discharge summary and post-discharge plan to be developed and provided, but this was not consistently done.