Incomplete Discharge Summary and Communication Failure at Discharge
Penalty
Summary
Facility staff failed to provide a completed discharge summary to a resident at the time of discharge. The resident, who had been admitted for short-term rehabilitation following a hospital stay for a fall with fracture, requested to leave the facility and was discharged. Upon discharge, the resident received paperwork that was incomplete, missing several pages, and lacking contact information for the home health agency that was supposed to provide continued care. The social services note indicated that home health services were arranged, but the discharge paperwork given to the resident did not reflect this information. The complainant, who assisted the resident, reported that attempts to contact facility social services for the missing information were unsuccessful. It was not until two weeks after discharge that the complainant received a complete discharge summary via email, which included all required sections and the home health agency's contact information. Additionally, there was a discrepancy in the discharge date communicated to the home health agency, which was told a different date than when the resident actually left the facility. Review of the initial discharge paperwork confirmed that multiple sections were not filled out, pages were missing, and no contact information for the home health agency was provided.