Failure to Complete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to ensure that discharge summaries, including a recapitulation of the residents' stays, were completed for two discharged residents. For one resident with a history of metabolic encephalopathy and transient cerebral ischemic attacks, clinical records showed that after an episode of altered mental status, the resident was transferred to the emergency room and subsequently admitted to the hospital. The Director of Nursing later informed the Area Agency on Aging that the resident would not be returning to the facility, but there was no documented evidence that a discharge summary or a recapitulation of the resident's stay was completed. Similarly, another resident with diagnoses of spinal stenosis and anxiety disorder requested discharge home with their spouse. The Director of Nursing and physician were notified, and the resident was discharged home after gathering belongings. However, as with the previous case, there was no documented evidence that a discharge summary, including a recapitulation of the resident's stay, was completed. Staff interviews confirmed that no additional documentation was provided to demonstrate that the attending physician had completed the required discharge summaries for either resident.