Failure to Complete Required Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to complete a required discharge summary for a resident who was discharged to another healthcare facility. Record review showed that while the resident's face sheet, medication orders, and belongings were provided at discharge, there was no comprehensive discharge summary in the clinical records. The available documentation, including the Summary Episode Note, did not address key elements such as the reason for discharge, date of discharge, reconciled medications sent to the new facility, personal belongings disposition, or physician signature. Additionally, the resident's care plan did not address discharge goals. Interviews with facility staff revealed inconsistent understanding and implementation of discharge documentation procedures. The nurse responsible for the discharge documented the transfer in progress notes and provided some information to the receiving facility, but did not complete a full discharge summary as required by facility policy. The DON and Administrator both indicated uncertainty or changes in policy regarding who was responsible for completing the discharge summary, and the process was not followed for this resident. The facility's own policy required a comprehensive discharge summary to be completed by the interdisciplinary team, but this was not done.