Incomplete Discharge Summary and Documentation
Penalty
Summary
The facility failed to ensure the completion of a discharge summary, including a recapitulation of the resident's stay and final status at discharge, for one resident who was discharged to the community. Record review showed that the discharge instruction form and the IDT recapitulation of stay were incomplete and unsigned, with missing information in key areas such as follow-up appointments, dietary recommendations, skin issues, patient instructions, and multiple service sections. The only section completed was Social Services, and there was no discharge summary completed or uploaded in the resident's electronic medical record (EMR). Interviews with facility staff revealed that the nurse responsible for the discharge did not make a copy of the completed medication recapitulation, as the resident was in a rush to leave. The nurse acknowledged that she was supposed to make a copy and place it in the discharge paperwork tray for scanning into the EMR, and to create a progress note detailing the discharge. The nurse stated she had been trained on the discharge process and had not previously had issues, but failed to follow the procedure in this instance. The ADON and DON confirmed that each department was responsible for completing their section of the discharge summary and that the summary was not completed for this resident. The facility's policy required that the discharge summary include a recapitulation of the resident's stay, a final summary of the resident's status, and documentation of medication reconciliation. The policy also required that an evaluation of the resident's discharge needs, the post-discharge plan, and the discharge summary be filed in the resident's medical record. In this case, these requirements were not met, resulting in incomplete documentation for the resident's discharge.