Incomplete Discharge Summary and Failure to Convey Required Information at Discharge
Penalty
Summary
The facility failed to provide a complete and timely discharge summary to the continuing care provider for one of two closed records reviewed. Specifically, the discharge summary for a resident who was discharged with ongoing needs for ostomy care, PEG tube care, and an active tracheostomy did not include a reconciliation of all pre-discharge and post-discharge medications, as required by facility policy. Additionally, the discharge summary lacked documentation of the resident's or responsible party's signature acknowledging agreement with the discharge plan. Instead, the section designated for the resident or responsible party's signature was signed and dated by the licensed nurse. Further review revealed that special care instructions were reviewed with the resident's family member after the discharge date, rather than at the time of discharge. There was also no evidence that the discharge summary, including the required components, was conveyed to the continuing care provider at the time of discharge. These findings were confirmed with the Nursing Home Administrator and Director of Nursing.