Failure to Complete Discharge Summary for Resident Leaving AMA
Penalty
Summary
A deficiency was identified when a resident left the facility against medical advice (AMA), and the facility failed to complete a required discharge summary. The medical record review showed that the resident expressed a desire to leave AMA, and this was documented by a nurse practitioner, who notified the primary care provider via voicemail and informed the Director of Nursing (DON) about the situation. Nursing progress notes indicated that the resident left the facility accompanied by paramedical transport, with no pain or distress noted, and that the nurse practitioner was made aware of the departure. Despite these actions, the medical record did not contain a discharge summary from the physician. Specifically, there was no documentation providing a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of pre-discharge and post-discharge medications, or a post-discharge plan of care. The DON confirmed during interviews that a discharge summary should have been completed for any resident leaving the facility, regardless of the circumstances, and acknowledged that this documentation was missing.