Incomplete Discharge Summaries and Missing Physician Signatures
Penalty
Summary
The facility failed to provide complete and compliant discharge summaries for three residents who were reviewed for discharge documentation. Each resident's discharge summary lacked essential information, such as a recapitulation of the resident's stay, including diagnoses, course of illness or treatment, pertinent laboratory and radiology results, and a final summary of the resident's status at the time of discharge. In several cases, sections of the discharge summary were left blank, including prognosis, special treatments or procedures, medical information, cognitive and psychosocial status, sensory and physical impairments, dental condition, and status upon discharge. Additionally, the discharge summaries were not signed by the attending physician as required. For the residents involved, the records showed that they had complex medical histories, including conditions such as upper respiratory infection, ureteral stones, obstructive uropathy, pyelonephritis, Alzheimer's dementia, chronic urinary tract infection, hydronephrosis, and post-surgical rehabilitation needs. Discharge planning was initiated upon admission, and arrangements for home health services, therapy, and follow-up with primary care providers were documented in progress notes and care plans. However, the official discharge summaries did not reflect a comprehensive account of the residents' medical status or the care provided during their stay, nor did they consistently document vaccine administration or declination. Interviews with facility staff, including nurses, the DON, and medical records personnel, revealed inconsistent practices regarding the completion and physician signature of discharge summaries. Staff reported that discharge summaries were completed by nurses at the time of discharge and were supposed to be signed by the physician, but in practice, this was not consistently done. The medical records staff also indicated that some discharge documents had not yet been scanned into the electronic medical record. Facility policies required that discharge summaries be provided to residents and included in the medical record, with specific content requirements that were not met in these cases.