Incomplete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to ensure the completion of discharge summaries for two discharged residents. For one resident who was admitted and later signed out against medical advice, the closed clinical record did not contain a discharge summary, including a summary of the stay or final diagnosis. This omission was confirmed during an interview with the Director of Nursing. Another resident was admitted, experienced a fall and a change in condition, and was subsequently sent to the hospital. The resident did not return and was discharged, but the closed clinical record also lacked a discharge summary with a summary of the stay or final diagnosis. This finding was similarly confirmed by the Director of Nursing during an interview.
Plan Of Correction
The need for a discharge summary was reviewed and the provider(s) completed a summary for both Resident #82 and #83. The discharge summary form was updated and provided to the nursing staff to be utilized for all residents being discharged under the supervision of a consultant physician, and all resident deaths under the supervision of the medical director and her PA for the purpose of providing the final diagnosis. The Medical Director and her PA provide a detailed discharge note with discharges that provides all of the information required per regulatory guidelines. Education was provided to licensed clinical nursing staff as to how and when the discharge summary should be utilized in accordance with facility discharge policy. Auditing will occur with a review of all discharges on a weekly basis for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.