Failure to Complete Physician Discharge Summary
Summary
The facility failed to ensure that a discharge summary was completed by the physician for one resident. The clinical record review of a resident revealed that the resident was admitted to the facility and later expired and was discharged. However, there was no documented evidence in the resident's clinical record that a discharge summary was completed by the physician upon the resident's death and discharge. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the required documentation.
Plan Of Correction
The facility cannot retroactively correct the presence of a physician discharge summary on resident 63. Residents who discharged in the last 30 days will be reviewed to determine the presence of a physician discharge summary. Nursing staff and physicians will be re-educated on completion of a discharge summary. Audits will be completed on residents who discharge to ensure completion of a discharge summary by the physician weekly x 4 weeks, then monthly x 2 months. Findings will be reviewed at monthly QAPI meeting.
Penalty
Two residents who were discharged did not have discharge summaries in their closed clinical records, as required. One resident left against medical advice, and another was sent to the hospital after a fall and did not return; in both cases, the records lacked a summary of the stay and final diagnosis, which was confirmed by the DON.
The facility failed to include a recapitulation of stay in the medical records of two residents. One resident, admitted with multiple serious conditions, ceased to breathe without a summary of their stay documented. Another resident, with conditions like diabetic ulcers and end-stage renal disease, was transferred to a hospital without returning, yet their record also lacked a stay summary. The absence of these summaries was confirmed by the Regional Clinical Consultant.
The facility failed to provide physician discharge summaries for three residents, missing final diagnoses and prognoses or causes of death. This was confirmed through record reviews and a DON interview.
A facility failed to complete a discharge summary with the physician's final diagnosis and cause of death for a resident who expired. The resident's clinical record lacked this documentation, as confirmed by a review and an interview with the administrator.
The facility failed to complete a discharge summary for a resident with dementia, prostate cancer, and high blood pressure, who was discharged after their spouse informed the facility of their non-return. The absence of this documentation was confirmed by a Regional Nurse Consultant.
Incomplete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to ensure the completion of discharge summaries for two discharged residents. For one resident who was admitted and later signed out against medical advice, the closed clinical record did not contain a discharge summary, including a summary of the stay or final diagnosis. This omission was confirmed during an interview with the Director of Nursing. Another resident was admitted, experienced a fall and a change in condition, and was subsequently sent to the hospital. The resident did not return and was discharged, but the closed clinical record also lacked a discharge summary with a summary of the stay or final diagnosis. This finding was similarly confirmed by the Director of Nursing during an interview.
Plan Of Correction
The need for a discharge summary was reviewed and the provider(s) completed a summary for both Resident #82 and #83. The discharge summary form was updated and provided to the nursing staff to be utilized for all residents being discharged under the supervision of a consultant physician, and all resident deaths under the supervision of the medical director and her PA for the purpose of providing the final diagnosis. The Medical Director and her PA provide a detailed discharge note with discharges that provides all of the information required per regulatory guidelines. Education was provided to licensed clinical nursing staff as to how and when the discharge summary should be utilized in accordance with facility discharge policy. Auditing will occur with a review of all discharges on a weekly basis for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Missing Recapitulation of Stay in Resident Records
Penalty
Summary
The facility failed to include a recapitulation of stay in the medical records of two residents, CR81 and CR83, as required by regulations. Resident CR81 was admitted on 10/29/22 with diagnoses including metabolic encephalopathy, bactremia, urinary tract infection, and severe protein calorie malnutrition. Progress notes indicated that Resident CR81 ceased to breathe on 11/15/24, yet the clinical record lacked a summary of the resident's stay and course of treatment at the facility. Similarly, Resident CR83 was admitted on 4/10/24 with conditions such as diabetic ulcers, end-stage renal disease, Type 2 Diabetes, and peripheral vascular disease. A progress note dated 11/10/24 indicated that Resident CR83 was transported to an acute hospital for evaluation and did not return to the facility. However, the clinical record for Resident CR83 also lacked a recapitulation of the resident's stay. The Regional Clinical Consultant confirmed the absence of these summaries during an interview.
Plan Of Correction
Resident # 81 and # 83 recapitulation was completed. Residents discharged and or ceased to breathe within the last 15 days will be reviewed for recapitulation of stay and will be completed. The Intradisciplinary team will be educated on the recapitulation of stay that is to be completed for any discharged or ceased to breathe by the Administrator. An audit will be conducted on residents that all discharged or ceased to breathe weekly for 4 weeks then monthly by the Administrator to ensure a recapitulation of stay is completed. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Missing Physician Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to ensure that a discharge summary, including the physician's final diagnosis and prognosis or cause of death, was completed for three discharged residents. This deficiency was identified during a review of closed clinical records and confirmed through a staff interview. Specifically, the records of three residents who were either discharged or expired at the facility lacked the required physician's discharge summary. Resident 35 was admitted to the facility and expired there, yet their record did not contain a discharge summary with the final diagnosis and cause of death. Similarly, Resident 187, who was discharged from the facility, and Resident 34, who was also discharged, both had records missing the physician's discharge summary with the final diagnosis and prognosis. The Director of Nursing confirmed the absence of these summaries during an interview.
Plan Of Correction
1. Residents 34, 35 and 187 had physician discharge summaries completed. 2. A 30 day look back was completed and physician discharge summaries were completed. 3. The DON was re-educated on ensuring physician discharge summaries are completed on discharge. The Administrative Assistant will complete discharge chart audits to ensure completion. 4. The NHA or designee will conduct an audit of discharged resident charts weekly x 4 weeks then monthly x 2 months to ensure completion of the physician discharge summary. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Missing Discharge Summary for Deceased Resident
Penalty
Summary
The facility failed to ensure the completion of a discharge summary, including the physician's final diagnosis and cause of death, for a resident who had been discharged. Specifically, the clinical record of a resident who was admitted on January 26, 2018, and expired on November 9, 2024, did not contain the required physician's discharge summary. This deficiency was identified during a review of the resident's closed clinical record on December 12, 2024. An interview with the facility administrator on the same day confirmed the absence of the necessary documentation.
Plan Of Correction
1. Physician discharge summary note placed note for Resident 35. 2. Re-education to all physicians and physician extenders on importance of placing discharge summary note within 30 days of resident discharge from the facility. 3. A 6-month (June 2024- December 2024) lookback of discharged residents was completed to ensure timely discharge note was placed. 4. DON/Designee will complete audit of discharged residents and physician note entry monthly x 3 and reported to QAPI.
Missing Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to ensure the completion of a discharge summary for a resident, identified as CR72, who was discharged from the facility. Resident CR72 was admitted on 3/12/24 with diagnoses including dementia, prostate cancer, and high blood pressure. On 10/08/24, the resident's spouse informed the facility that Resident CR72 would not be returning. However, upon review of the closed clinical record, it was found that there was no discharge summary documenting the resident's stay and course of treatment. This deficiency was confirmed during an interview with the Regional Nurse Consultant on 12/05/24.
Plan Of Correction
1. Resident R72's discharge summary was opened and completed. 2. The last 10 closed charts will be audited for discharge summaries. All closed charts will be reviewed going forward to ensure discharge summary is in the closed file. 3. Nursing Home Administrator or designee will educate Interdisciplinary Team, which includes medical records, on discharge summaries to ensure that staff understands they have to be completed on all discharged residents and in the file prior to closing. 4. Nursing Home Administrator or designee will audit to ensure discharge summaries are included in closed charts. Audits will be completed on all discharged residents for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is met.
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