Failure to Document Resident Discharge Summary
Penalty
Summary
The facility failed to provide a final summary of a resident's status at discharge, as required. The resident in question had multiple diagnoses, including infection and inflammatory reaction due to a knee prosthesis, MRSA, pain, cognitive decline, major depressive disorder, and dysphagia. Documentation showed the resident required significant assistance with activities of daily living (ADLs) such as eating, oral hygiene, toileting, transfers, and bed mobility. The care plan indicated ongoing skilled services to help the resident regain strength and return home, with identified risks including further ADL decline, falls, incontinence, skin breakdown, and pain. On the day of discharge, the resident's husband arrived to take her home, and nursing staff notified the physician of the discharge. However, the medical record did not contain a summary of the resident's stay or a recompilation of her care, as required by facility policy. Interviews with nursing staff confirmed that it was the responsibility of the nurse in charge, or the DON if not completed, to document this summary, but it was not done in this case.