Failure to Complete Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to complete a required discharge summary and medication reconciliation for a resident who was discharged home. The resident, an older adult male with multiple complex diagnoses including traumatic subarachnoid hemorrhage, Type 1 diabetes, chronic kidney disease, cerebral infarction, and other significant medical conditions, was admitted from a short-term general hospital and had a moderate cognitive impairment as indicated by a BIMS score of 10. Upon planned discharge, there was no documentation in the clinical record of a discharge summary or reconciliation of pre-discharge and post-discharge medications, both prescribed and over-the-counter. Interviews with facility staff revealed that the RN was unable to locate the discharge summary for the resident, and the DON confirmed that the summary had not been completed. The DON acknowledged that discharge summaries are required for all residents who leave the facility and noted the risks associated with not having this documentation, such as the lack of medication reconciliation and missed opportunities for care planning and follow-up appointments. The administrator also confirmed that discharge summaries should be completed and that there was no oversight to ensure that nursing staff managers were completing them for all discharges. A review of the facility's policy indicated that discharge summaries must include a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all medications, and a post-discharge plan of care developed with the resident and their representative. In this case, these required elements were missing from the resident's record at the time of discharge.