Incomplete Discharge Summary and Lack of Catheter Care Education
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for a resident with a history of stroke and neuromuscular bladder dysfunction, who was discharged with an indwelling urinary catheter. The discharge summary was left incomplete, lacking the name and contact information of the home health company responsible for post-discharge care. The social services section did not document the home health provider, and the summary remained in progress at the time of review. The resident was discharged home without this critical information being finalized in the record. Additionally, the facility did not provide or document education regarding catheter care to the resident's representative prior to discharge. Interviews revealed that the nurse responsible for the discharge did not deliver formal catheter care education, and the resident's representative confirmed not receiving any such instruction or related paperwork, aside from a medication list and prescriptions. The representative had to independently research catheter care until home health services began. The discharge summary was not updated to reflect the correct home health provider after a change was made, and the summary was not properly closed.