Incomplete Discharge Summaries and Missing Required Documentation
Penalty
Summary
The facility failed to provide complete and compliant discharge summaries for two of three residents reviewed for discharge. For both residents, the discharge summaries were missing essential elements required by facility policy and federal regulations, including a recapitulation of the residents' stay with diagnoses, course of illness or treatment, pertinent lab, radiology, and consultation results, a final summary of the residents' status at the time of discharge, and a reconciliation of all pre-discharge medications with post-discharge medications. For one resident, the medical record review showed an incomplete discharge summary document, lacking the required information and only partially filled out. The document was provided to the resident at discharge, but it did not include a comprehensive summary of the resident's stay, status at discharge, or medication reconciliation. Interviews with facility staff confirmed that the discharge summary was not completed as required and that the responsibility for discharge documentation was not clearly followed. For the second resident, the discharge documentation included a progress note and a discharge summary form, but these also lacked critical information. There was no documentation of the reason for discharge, no list of medications provided at discharge, and no record of instructions given to the resident. The discharge summary form was not signed by the resident and did not include a summary of the resident's diagnoses, treatment course, or status at discharge. Staff interviews confirmed these omissions and acknowledged that the required documentation was not present in the resident's medical record.