Failure to Document Required Recapitulation Summary at Discharge
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to document a recapitulation, which is a complete summary of a resident's stay from admission to discharge, for a resident who initiated their own discharge. Record review showed that the discharge summary and plan of care for this resident did not include the required recapitulation summary. During an interview, the Social Service Director confirmed that the recapitulation summary was not part of the facility's discharge process and that they were unaware of the regulatory requirement for this documentation.