Failure to Complete Required Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a complete discharge summary was prepared for a resident at the time of a planned discharge. According to the facility's discharge and transfer policy, a discharge summary must be completed for all residents being discharged home or transferred to another facility. This summary should include a recapitulation of the resident's stay, a final summary of the resident's status at discharge, a list of medications, follow-up appointments, and other pertinent information to ensure continuity of care. However, record review revealed that for one resident, this process was not fully followed. The resident in question had multiple diagnoses, including vascular disease, heart failure, a left shoulder cuff tear, long-term use of diuretics and anticoagulants, and a history of stroke. The resident's care plan indicated a goal of returning home with family support, and various care conferences and social service notes documented ongoing discharge planning, including referrals to assisted living facilities and coordination with the family. Despite these efforts, the medical record lacked a comprehensive discharge summary from all departments, as required by policy. Progress notes and the physician's discharge summary provided some information about the resident's medications and discharge orders, but did not include a full recapitulation of the resident's stay or a detailed final summary of the resident's status at discharge. The Director of Nursing confirmed that the electronic medical record should contain a discharge summary from all departments, including details on medications, home health arrangements, and follow-up appointments, but this was not present for the resident in question.