Failure to Complete Required Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a required discharge summary for one of three closed records reviewed. The facility’s policy, last reviewed on 04/09/2025, states that when a discharge is anticipated to a private residence or another nursing care facility, a discharge summary and post-discharge plan must be developed to assist the resident’s adjustment, and that a copy of the discharge summary must be provided to the resident, the receiving facility, and filed in the resident’s medical record. Record review showed that Resident #123 was admitted on an unspecified date and discharged on 11/07/2025, but the medical record contained no documentation of a completed discharge summary. During a record review and interview on 01/28/2026 at 2:06 p.m., the Social Services Director confirmed that the resident had been discharged on 11/07/2025 and further confirmed that a discharge summary was not completed for this resident. No additional medical history or condition details for the resident at the time of discharge were documented in the report.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.