Failure to Complete Discharge Recapitulation for Resident Stay
Penalty
Summary
The deficiency involves the facility’s failure to complete a recapitulation of a resident’s stay and course of treatment upon discharge. The resident had diagnoses of dementia, acute blood loss anemia, and a lower gastrointestinal bleed, and an admission 5-Day Medicare MDS documented a BIMS score of nine, indicating moderately impaired cognition. The resident required partial staff assistance with toileting hygiene, showers, dressing, personal hygiene, and transfers. The care plan documented that the resident was to be discharged from the facility and directed staff to encourage verbalization of fears and concerns, clarify misconceptions, and provide the resident and family with opportunities to attend care plan conferences, participate in discharge planning, and consider alternative care options. Nurse’s notes documented that the resident was admitted with a lower gastrointestinal bleed and anemia and later discharged home with her husband. However, the clinical record lacked a completed recapitulation summarizing the resident’s stay and course of treatment in the facility. On interview, the Administrative Nurse confirmed that a recapitulation upon discharge was not completed for this resident. The facility’s Discharge Planning policy stated that discharge planning is part of the comprehensive care plan and that all discharge planning activities are to be documented in the resident’s clinical record, but the required recapitulation was not present in this case.
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