Failure to Complete Required Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged to another care setting. Specifically, the discharge summary was missing key elements such as a recapitulation of the resident's stay, including 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. The resident's record only included a final progress note indicating the resident was discharged in stable condition with her daughter, had her medications and belongings, and that the room was empty, but did not provide the required detailed clinical information or individualized care instructions. The resident involved had a history of cerebrovascular disease, type 2 diabetes mellitus, adjustment disorder with anxiety, morbid obesity, hemiplegia, cerebral infarction, and muscle wasting. She had moderately impaired cognitive function, used a wheelchair, and required assistance with activities of daily living. During interviews, the Social Service Designee (SSD) confirmed that the discharge summary was not completed and was unable to provide a reason for the omission. Review of facility policy indicated that the SSD and/or Case Manager, with input from the Interdisciplinary Team, are responsible for ensuring a comprehensive discharge planning process, which was not followed in this instance.