Incomplete Discharge Summary Documentation for Discharged Resident
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of the resident's stay and a final summary of the resident's status for one resident who was discharged to the community. Record review showed that the discharge summary assessment for this resident was initiated but left incomplete, with only the Therapy section filled out and all other required sections, including Nursing, Dietary, Social Services, Activity, Reason for Discharge, Medical Summary, and Acknowledgement, left blank. The Social Worker, who was responsible for completing the Social Services section, confirmed during an interview that he did not consistently enter documentation into the resident's medical record and that the completion of the discharge summary was overlooked. The resident in question had intact cognition and no active discharge plan in place at the time of the quarterly MDS assessment. Although the Social Worker stated that a care plan meeting was held with the resident and their representative to discuss discharge plans and needs, there was no documented evidence of this in the medical record. The Administrator was unaware that the discharge summary had not been completed and stated that all sections should be completed by the respective departments according to regulatory guidelines.