Incomplete Discharge Summary Provided at Resident Discharge
Penalty
Summary
A deficiency was identified when a resident was discharged to a group home with an abdominal drain and receiving total parenteral nutrition (TPN). Upon review of the resident's closed medical record and discharge summary, it was found that the nursing instructions section was incomplete. Specifically, the discharge instructions lacked documentation regarding TPN management, abdominal drain care, patient education provided, and a complete list of medications. The facility's policy required that a licensed nurse complete all applicable nursing sections of the discharge instructions prior to discharge. Interviews with facility staff, including the social worker and the Director of Nursing (DON), confirmed that each discipline is responsible for their respective sections of the discharge summary, with nursing staff responsible for medication and treatment areas. The DON acknowledged that the nursing sections of the discharge summary were incomplete and did not accurately reflect the resident's status at the time of discharge, despite the resident being sent home with TPN supplies, an abdominal drain, and prescribed medications.