Failure to Send Complete Discharge Summary to Receiving SNF
Penalty
Summary
The deficiency involves the facility’s failure to provide a complete Discharge Summary/Post Discharge Plan of Care to the receiving SNF when a resident was transferred. The resident had multiple significant diagnoses, including ESRD, DM, schizophrenia, depression, and anxiety disorder, and had been assessed as unable to make reasonable and consistent decisions or understand and make medical decisions. Prior documentation showed the resident had exhibited severe behavioral issues, including banging hands on the wall and attempting to grab staff members’ private parts, which led to a psychiatric hold and subsequent readmission. An IDT care conference documented that discharge options to a more appropriate SNF capable of managing the resident’s behavioral needs were discussed with the responsible party. On the day of transfer, a physician’s order directed that the resident be transferred to another SNF with all remaining medications, and that a representative from the receiving facility would pick up the resident’s medications, belongings, and discharge paperwork. Nursing progress notes documented that the RN Supervisor was unable to reach licensed staff at the receiving facility despite multiple calls, but that a representative from the receiving facility would pick up the resident’s medications, cigarettes, and belongings. The facility had initiated a Discharge Summary/Post Discharge Plan of Care the day before transfer, which included instructions to follow up with the primary care physician, details of the hemodialysis facility, treatment schedule and transportation, monitoring of vital signs and overall well-being, one-on-one supervision and safety needs, blood sugar checks, assistance with ADLs, and the latest hemoglobin result with associated anemia treatment. Despite this, the RN Supervisor provided only the face sheet with the transfer discharge report/transfer medication list, along with the resident’s belongings and medications, to the receiving facility’s representative and did not print or send the Discharge Summary Instructions. The RN Supervisor stated he believed the Discharge Planner had already sent the discharge summary to the receiving facility and that he was told only to send the transfer medication list, medications, and belongings. The responsible party later reported that the receiving SNF could not provide discharge instructions from the sending facility. Review of facility policies titled “Transfer or Discharge Documentation” and “Discharging the Resident” showed that the facility’s procedures required that a copy of the resident’s discharge summary and other appropriate documentation be communicated to the receiving facility and that a transfer summary and telephone report be completed, which did not occur in this case.
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