Incomplete Discharge Summary Due to Missing Skin Assessment
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to complete a discharge summary for one resident, as required by its own policy and accepted professional standards. During a review of the resident's discharge summary, it was found that the section for skin assessment was left blank, indicating that no skin assessment was completed at the time of discharge. This was confirmed during an interview with an LVN, who stated that the skin assessment was not performed or documented. The facility's policy specifies that a discharge summary must include a summary of the resident's status, including a description of medically defined conditions and prior medical history, but this requirement was not met in this instance.