Failure to Complete Discharge Summaries and Obtain Physician Discharge Orders
Penalty
Summary
The deficiency involves the facility’s failure to complete required discharge summaries/recapitulations of stay and to obtain physician discharge orders prior to residents leaving the facility. For one resident admitted with anemia, diabetes mellitus, morbid obesity, bipolar disease with psychotic features, and congestive heart failure, the medical record showed dependence on staff for bathing, toilet hygiene, bed mobility, transfers, and set-up assistance with eating, and documented a discharge date of 10/16/25. However, there was no documentation of a discharge summary or recapitulation of stay, and no evidence that physician discharge orders were obtained before the resident’s discharge. For another resident admitted with multiple sclerosis, left hemiplegia, cerebral infarction, diabetes mellitus, and stage IV chronic kidney disease, the record showed the resident was cognitively intact, dependent for bed mobility, bathing, toileting, and transfers, and received nutrition via tube feeding. This resident was transferred to the hospital, readmitted, and later discharged to another facility on 09/24/25. The medical record lacked documentation of a discharge summary/recapitulation of stay and did not show that physician discharge orders were obtained prior to discharge. The DON confirmed that both residents’ records were missing these required elements, despite facility policies stating that discharges must occur only upon a physician’s written order and that a discharge summary including recapitulation of stay, final health status, medication reconciliation, and a post-discharge plan of care must be completed when discharge is anticipated.
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