Failure to Provide Required Discharge Summary and Notification
Penalty
Summary
The facility failed to complete and provide a discharge summary for a resident who was transferred to a hospital. The discharge summary was required to include a recapitulation of the resident's stay, diagnoses, course of treatment, pertinent laboratory results, a final summary of the resident's status, and a reconciliation of all pre-discharge medications with post-discharge medications. Record review showed that there was no documented discharge summary for the date the resident was sent to the hospital, and staff interviews confirmed that the necessary clinical documents were not prepared or sent to the receiving facility. The resident involved had a history of schizophrenia, anemia, and hypertension, and had exhibited both physical and verbal behavioral symptoms. The transfer to the hospital was ordered for further evaluation and treatment, but the facility did not provide the required clinical discharge summary or documentation to the hospital. Staff interviews revealed confusion about responsibilities, with the nurse on duty stating she did not complete the discharge summary due to a busy day, and the social worker indicating that the former administrator and DON oversaw the transfer. The physician reported giving a verbal report to the hospital but did not prepare a written discharge summary. Additionally, the facility failed to provide the required notice of discharge to the Office of the Long-Term Care Ombudsman. The Ombudsman confirmed that she was contacted for a list of alternative placements but was not provided with the necessary discharge notice or clinical summary. The facility's own policy required notification of the attending physician, the receiving facility, and the resident's representative, as well as preparation of a transfer form and forwarding of the medical record within 24 hours, but these steps were not documented as completed.