Failure to Complete Required Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a required discharge summary for a resident who was discharged to another nursing home. The resident, an elderly female with severe cognitive impairment, dementia, hypertension, and malnutrition, was discharged as documented in the MDS assessment and progress notes. While a progress note and a physician discharge summary were present, there was no evidence in the clinical record of a comprehensive discharge summary that included a recapitulation of the resident's stay, diagnoses, course of illness or treatment, pertinent lab, radiology, and consultant results, and a final summary of the resident's status at discharge. Interviews with facility staff revealed that the nurse responsible for the discharge did not complete the discharge summary due to unfamiliarity with a new system and only documented a progress note after being advised by the ADON. The ADON and DON both stated that the nursing team was responsible for ensuring the discharge summary was completed, but neither was aware that it had not been done. The facility's policy required notification of the resident or representative, documentation of the discharge, and provision of written discharge instructions, but these requirements were not fully met in this case.