Failure to Complete Discharge Summary for Non-Return Anticipated Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to complete a discharge summary for one resident whose discharge was not anticipated to return. The resident was admitted with diagnoses including left foot drop, left wrist drop, and a fracture of the lower end of the left radius. A discharge MDS indicated that the resident’s return was not anticipated and that she was cognitively independent for daily decision-making. Progress notes showed that on December 10, 2025, a referral was sent to another facility at the request of a family member, and on December 11, 2025, the receiving facility obtained insurance authorization and accepted the resident, with transfer scheduled for December 12, 2025. A final progress note on December 12, 2025 documented that a report was called to the receiving facility and the resident was sent with her belongings and medications. Further review of the clinical record did not reveal a discharge summary for this resident. During interviews, social services staff stated that discharge summaries are completed by nursing and social services and include information such as home health agencies, DME needs, future provider appointments, Ombudsman contact, and facility contact information, but that they do not complete discharge summaries for residents who transfer to another facility and do not document anything in the chart in those cases. The MDS coordinator/LPN confirmed that, based on the MDS indicating the resident’s return was not anticipated, this situation should be considered a discharge and that no discharge summary could be located. The Social Services Director described a discharge as leaving to go home and a transfer as moving to another facility, and explained that discharge summaries are only done when a person is discharging to their place of residence, with transfer information instead communicated by nursing report. When surveyors requested a discharge summary policy, the administrator reported that the facility did not have one, and the existing Discharge Planning Process policy did not contain language about a resident discharge summary.
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