Failure to Provide Discharge Order and Summary for Discharged Resident
Penalty
Summary
A deficiency occurred when a resident was discharged without a physician's discharge order or a discharge summary being maintained in their medical record. The resident, who had a history of atrial fibrillation, myocardial infarction, asthma, hypertension, and elevated liver enzymes, was admitted to the facility and later discharged. Upon review of the resident's electronic medical record (EMR), it was confirmed by the MDS Registered Nurse, Medical Director, Director of Nursing, and Social Worker that neither a discharge order nor a discharge summary was present in the EMR or provided to the resident at the time of discharge. Interviews with facility staff revealed that it was the responsibility of the discharging physician to provide both a discharge order and a discharge summary, which should have been given to the resident and forwarded to the primary care provider for continuity of care. The facility's policies required a written physician order for discharge and completion of a discharge summary within 14 days, including details about the resident's medical condition, current status, treatments, and medications. These requirements were not met for the resident in question.