Incomplete Transfer/Discharge Documentation for Discharged Residents
Penalty
Summary
The facility failed to complete required transfer or discharge reports for three residents who were discharged or transferred. Record reviews showed that for each of these residents, the transfer/discharge reports were missing critical information such as the chief complaint or reason for transfer, relevant information including detailed instructions for ongoing care, the location to which the resident was transferred or discharged, and a final summary of the resident's status at the time of discharge. The facility's own policy requires that discharge summaries include a recapitulation of the resident's stay, a final summary of the resident's status, and that this information be available for authorized individuals and agencies with appropriate consent. Interviews confirmed that the administrator was aware that the transfer/discharge reports for these residents were incomplete and acknowledged that the reports should have been completed according to policy. The deficiency was identified through both interviews and record reviews, which consistently showed the absence of required documentation for all three sampled residents investigated for transfer and discharge requirements.