Missing Physician Discharge Summary for Discharged Resident
Penalty
Summary
Facility staff failed to provide a physician discharge summary for one of eight sampled residents who was discharged home. The resident had multiple diagnoses, including chronic diastolic congestive heart failure, schizophrenia, unspecified dementia, major depressive disorder, and a history of tobacco use. Documentation in the medical record included nursing and social work progress notes detailing the resident's admission, ongoing care, and discharge process. The notes indicated that the resident was alert, verbally responsive, and discharged in stable condition to an assisted living apartment, with personal belongings and care instructions transferred accordingly. Despite these records, there was no documented evidence of a physician discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, or a reconciliation of all pre-discharge medications. The absence of this required documentation was confirmed during a face-to-face interview with the Director of Nursing, who acknowledged the deficiency in the resident's medical record.