Incomplete Discharge Summary Documentation
Penalty
Summary
The facility failed to ensure the completion of a discharge summary for one resident who was reviewed for discharge. Specifically, the discharge summary for a female resident with diagnoses including bipolar disorder, schizophrenia, and depression was not completed following her discharge. The resident's electronic health record lacked a completed Minimum Data Set (MDS) assessment, and the interdisciplinary discharge summary form was missing key sections such as the recapitulation of the resident's stay, physician signature, social services summary, activity summary, and therapy services summary. Nursing notes indicated the resident left the facility against medical advice, with all medications and belongings provided to her at the time of departure. Interviews with facility staff revealed that the social worker had only recently started at the facility and completed only his portion of the discharge summaries for residents. Other departments were responsible for their respective sections, and the medical records staff was tasked with ensuring the entire discharge summary was completed. However, in this case, the medical records staff did not identify the incomplete discharge summary, and the director of nursing confirmed that all departments should have completed their sections. The facility was unable to provide a discharge summary policy prior to the survey exit.