Failure to Complete Required Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a required discharge summary, including a recapitulation of the resident’s stay and final status at discharge, for one resident who was permanently discharged. The resident was an elderly female with dementia, metabolic encephalopathy, and unspecified protein-calorie malnutrition who had been admitted and later discharged to another nursing home/LTC facility with a secured unit. The discharge MDS indicated a discharge with return not anticipated, and a nurse’s progress note documented that the resident was transferred to a new facility with personal belongings and medications sent. However, review of the electronic medical record showed that no discharge summary was present for this resident. Interviews revealed confusion and lack of clarity among staff regarding responsibility for completing the discharge summary. The Regional Nurse Consultant stated that a discharge summary with a recapitulation of the resident’s stay was expected within 72 hours of discharge and was part of the overall discharge process initiated at admission. The Social Worker reported arranging the transfer after being instructed by the Administrator and DON to find a secured placement due to exit-seeking behavior and confirmed agreement from the responsible party, but stated she did not know who was responsible for the discharge summary and had not been instructed on this. The DON stated that nursing was responsible for initiating the discharge summary in the electronic record, including medications sent, care received, and medical history, and acknowledged that the facility had recently changed electronic record systems and staff were still learning the process. The Administrator stated the discharge summary should be completed the day of or the day after discharge and be part of the electronic health record, and the facility’s policy required a discharge summary that included a description of the resident’s diagnoses, medical history, course of illness, test results, functional status, ADL ability, nutritional status, and medication therapy, with a copy provided to the resident and receiving facility and filed in the medical record.
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