Failure to Complete Required Discharge Summaries and Goals for Three Discharged Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Discharge Summary and Plan policy for three residents reviewed for discharge planning. The policy, dated 10/2022, requires that when a discharge is anticipated, staff complete a discharge summary including a recapitulation of the resident’s stay, a final summary of status at discharge, and an individualized post‑discharge plan developed by the interdisciplinary team with the resident and family. The policy also requires that an evaluation of discharge needs, the post‑discharge plan, and the discharge summary be provided to the resident and filed in the medical record. For all three residents (R1, R2, and R3), the electronic medical record in Point Click Care showed a “Discharge Summary and Recap of Stay” assessment that was due and highlighted in red as overdue or not completed, and the DON confirmed these discharge summaries were not completed as expected on the day of discharge. R1, admitted for a respite stay with diagnoses including progressive supranuclear palsy and palliative care needs, had a care plan focus on preparing for discharge, but on the discharge date the only progress note entry was a medication entry with the word “discharged” and no discharge summary was present. R2, admitted with diagnoses including UTI, muscle weakness, cognitive communication deficit, and vascular dementia, was discharged to a private residence, but the “Discharge Summary and Recap of Stay” assessment in the record was highlighted in red and could not be opened, and the DON stated this meant it was not completed. R3, admitted with a left femur neck fracture and weakness and discharged home with home health PT and OT ordered, had progress notes on the day of discharge documenting pain monitoring and analgesic orders but no discharge summary or mention of discharge, and the care plan dated 12/10/25 did not include a discharge goal. The DON acknowledged that discharge summaries should be completed on the day of discharge and that residents’ care plans should include a discharge goal, which was not done for these residents.
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