Failure to Complete Required Discharge Summary and Planning
Penalty
Summary
A resident with multiple complex medical conditions, including acute and subacute endocarditis, methicillin resistant staph aureus, anxiety, obesity, obstructive sleep apnea, hypertension, congestive heart failure, pacemaker, dysphagia, and muscle weakness, was admitted and required partial to moderate assistance with activities of daily living and hygiene. The resident was cognitively intact and used a wheelchair for mobility. Review of the medical record and baseline care plan showed that while goals for safety, nutrition, medication, and activities were documented, there was no evidence that a discharge summary or discharge planning process was completed as required by facility policy. The facility's policy mandates that discharge notices include the reason for discharge, the effective date, and the location to which the resident is transferred or discharged. The administrator confirmed that the required discharge summary was not completed for this resident.