Failure to Document Discharge Summary at Time of Resident Discharge
Penalty
Summary
A deficiency was identified when a resident was discharged from the facility without a discharge summary being written at the time of discharge. The resident had multiple diagnoses, including mild cognitive impairment, C. difficile enterocolitis, hyperlipidemia, hypertension, malnutrition, and Parkinson's Disease, and was assessed as having severely impaired cognition. The care plan for this resident included interventions for anticipated short-term placement and discharge to the community, with specific instructions for arranging post-discharge support, referrals, and communication with the resident and family regarding services and follow-up needs. Upon review, the resident's progress notes did not contain a final discharge summary note from the LPN responsible for the discharge. Interviews with the Assistant Director of Nursing and the LPN confirmed that the facility's policy requires a discharge note at the time of discharge, but this was not completed for the resident. The facility's own Transfer/Discharge/Bed Hold Policy also specifies that transfer or discharge must be documented in the medical record and communicated to the receiving provider, which was not done in this case.