Failure to Provide Discharge Summaries and Documentation During Resident Transfers
Penalty
Summary
The facility failed to complete and provide discharge summaries and necessary documentation to the receiving facilities for two residents who were transferred. For one resident with intact cognition and diagnoses including cellulitis, lymphedema, and hypertension, the electronic health record did not contain a completed discharge summary or evidence of communication with the receiving provider. The receiving facility reported delays in obtaining admission orders, which resulted in delayed medication and treatments, as the resident arrived without any paperwork or discharge summary. The facility's own discharge planning policy requires all relevant information to be provided in a discharge summary to facilitate a smooth transition and avoid unnecessary delays. Another resident, also with intact cognition and diagnoses of depression, anemia, and hypertension, was discharged to another facility without a completed discharge summary or documented communication with the receiving provider. The resident reported that the discharge process was rushed, and no discharge paperwork or orders were sent with her. The receiving facility confirmed that no discharge records accompanied the resident and that they had to repeatedly contact the prior facility to obtain the necessary information for care.