F0628

D

Failure to Complete Discharge Summaries and Provide Essential Transition Information

Taylor, Michigan Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete required discharge summaries, including a recapitulation of stay and essential discharge information, for two residents. One resident, who was being discharged to stay with her daughter, had a Recapitulation of Stay (Discharge Summary) form dated the day of discharge that was largely blank. Sections 1a–8, which should have contained the summary of stay, continuing care information, and special instructions or precautions, were not completed. The Additional Information section, which should have included contact information, was also blank, leaving the discharge summary incomplete despite the resident’s multiple diagnoses, including cerebral infarction affecting the dominant side and a fractured left humerus.

Another resident, discharged home after surgical repair of a fractured left femur and with additional diagnoses including anxiety and left eye blindness, did not have any Recapitulation of Stay (Discharge Summary) form or discharge summary in the EHR. The resident reported that home care had been set up but that it took a week after returning home to reach anyone, and the discharge paperwork provided did not include phone numbers for the home health care agency. The resident’s “My Transition Home-Discharge” form was significantly incomplete, lacking the home health agency phone number, follow-up appointment information, and entries in the sections for contact information, medication information, nursing instructions, dietary information, and discharge instructions. The SW and DON both confirmed, upon review of the record, that there was no discharge summary or recapitulation of stay, despite the facility’s written policy requiring a discharge summary that includes a recapitulation of the resident’s stay and medication reconciliation.