Incomplete Discharge Summary and Recapitulation of Stay
Penalty
Summary
The facility failed to complete a discharge summary, specifically a recapitulation of stay, for a resident who was discharged to another facility. The recapitulation of stay was missing required information from multiple departments, including Social Services, Nursing Services, Activities, Dietary Services, and Rehabilitation Services. The document was neither completed nor signed, and this omission was identified during a review of the resident's records. The resident in question had a medical history that included a urinary tract infection, type 2 diabetes mellitus with hyperglycemia, and an unspecified head injury. During an interview, the DON stated that it was expected for each department to complete their respective sections of the recapitulation of stay, but was unsure why it had not been done in this case. The facility did not have a written policy regarding the completion of recapitulation of stays, but the administrator indicated that the facility was expected to follow state guidelines. The lack of a completed recapitulation of stay was noted as a deficiency in the resident's discharge process.