Failure to Provide Comprehensive Discharge Summary and Proper Medication Transfer
Penalty
Summary
The facility failed to provide the receiving facility with a comprehensive discharge summary and appropriate handling of medications for a resident transferred out of the facility. A complaint investigation revealed that the receiving facility reported not receiving a discharge summary of the resident’s stay and not receiving all of the resident’s medications as discussed during pre-discharge planning. During interview, the discharging LPN stated she was not familiar with the discharge process, was unsure how to handle narcotics, and therefore did not send any narcotic medications with the resident, although she reported sending non-narcotic medications. Review of documentation showed a miscellaneous note indicating that a neurology team from the receiving facility later came to pick up some narcotics and signed a paper with a nurse from the discharging facility. When interviewed, the DON stated that narcotics are only sent with a physician’s order and produced printed prescriptions for the resident; however, record review did not show any physician order for narcotics to be sent with the resident, nor any documentation that a discharge note summarizing the resident’s stay, including all courses of treatment and care, was provided to the receiving facility. The deficiency centers on the lack of a documented discharge summary and the absence of documented orders and procedures for sending the resident’s narcotic medications at the time of discharge, as identified through interviews with staff and review of the resident’s records and the complaint file.
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.