Failure to Provide Written Discharge Summary and Recapitulation of Stay
Penalty
Summary
The facility failed to provide a written discharge summary or recapitulation of the stay for a resident who was discharged to the community. The resident's electronic health record (EHR) documented multiple communications and orders regarding the discharge, including physician orders, progress notes about discharge planning, and documentation that the resident's family assisted with moving belongings. Staff documented a discharge meeting where the medication list was reviewed and noted that the resident had independently arranged follow-up appointments and transportation. However, the EHR lacked evidence that a written discharge summary or recapitulation of the stay was provided to the resident or their family. A printed copy of a Planned Discharge - Interdisciplinary evaluation was later provided, but it was incomplete and did not include required elements such as the resident's condition at admission, discharge destination, to whom the resident was released, disposition of medications or personal possessions, aftercare instructions, or a summary of the stay. Interviews with staff confirmed that the recapitulation should have been present in the medical record, and the resident confirmed she did not receive a written discharge summary. The facility's policies did not address the requirement to provide a written discharge summary or recapitulation of the stay.