Incomplete Discharge Summary Provided at Resident Transfer
Penalty
Summary
Facility staff failed to complete a discharge summary, including a recapitulation of the resident's stay and a final summary of the resident's status, at the time of discharge for one resident. The resident had multiple complex diagnoses, including seizures, COPD, hypertension, anxiety, heart failure, a history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. The resident was assessed as having moderate cognitive impairment. A 30-day discharge notice was issued due to the facility's inability to meet the resident's needs and concerns for health and safety. The discharge process involved multiple staff and hospice coordination, with the hospice social worker and aide facilitating the resident's transfer to another facility. Upon review of the clinical record, the discharge summary was found to be incomplete. The section for the recapitulation of stay and summary of diagnoses was left blank, as were the nursing summary, medication reconciliation, dietary summary (except for height and weight), activities, therapy, and final disposition sections. Interviews with facility and hospice staff confirmed that the discharge summary was not fully completed or provided to the receiving provider at the time of transfer, as required by facility policy. The deficiency was discussed with facility leadership, who acknowledged the incomplete documentation and stated that the discharge was unexpected on the day it occurred.