Failure to Complete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to ensure the completion of discharge summaries, including a recapitulation of the resident's stay and final status at discharge, for two residents who were reviewed for discharge documentation. For both residents, the electronic medical record (EMR) lacked evidence of a completed discharge summary following their discharge to the community. One resident, a female with diagnoses of pneumonia, hypertension, and dementia, was discharged back to assisted living, while the other, a female with cerebral infarction, hypertension, and kidney disease, was discharged home accompanied by a family member. In both cases, the progress notes documented the discharge event, but no formal discharge summary was present in the EMR. Interviews with facility staff revealed that the nurse responsible for discharging the resident was expected to complete the discharge summary and enter it into the EMR. The MDS coordinator and the DON both confirmed that discharge summaries were missing for the two residents and acknowledged that the summaries should have been completed at the time of discharge. The facility's policy required a discharge summary to be developed when a resident's discharge was anticipated, but this was not followed in these instances.