Failure to Complete Discharge Summaries Timely
Summary
The facility failed to ensure that a physician's discharge summary was completed within 30 days of discharge for two residents. Resident 167, who expired on December 12, 2024, did not have a discharge summary completed by the physician within the required timeframe. Similarly, Resident 168, who was discharged home on November 19, 2024, also lacked a timely discharge summary. This deficiency was confirmed during an interview with the Director of Nursing on January 31, 2025, at 12:30 p.m., who acknowledged that the discharge summaries for both residents were not completed within the mandated 30-day period.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. The NHA/designee educated physicians on timely completion of discharge summaries. The Medical Records Director/designee will audit discharged residents' charts to ensure a discharge summary is completed within 30 days of discharge by the physician. Audits will be done weekly x 4 weeks then monthly thereafter. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Penalty
The facility failed to complete discharge summaries within the required 30 days for two residents. One resident was admitted and discharged within a short period, while another was discharged to the hospital, yet both lacked timely discharge summaries. Interviews with the Nursing Home Administrator confirmed these findings, indicating a lapse in adherence to the facility's policy on discharge documentation.
A facility failed to complete a discharge summary within the required 30 days after a resident's death. The resident was admitted in 2021 and passed away in 2024, but the discharge summary was not completed until several months later. This was confirmed by the Nursing Home Administrator.
A facility failed to complete a discharge summary within 30 days of a resident's death. A review of the resident's closed clinical record showed that while the resident was documented as deceased, the required discharge summary, including the final diagnosis and cause of death, was not completed in the specified timeframe. This deficiency was identified through record review and staff interviews.
Failure to Complete Timely Discharge Summaries
Penalty
Summary
The facility failed to complete discharge summaries within the required 30 days for two residents, as evidenced by a review of closed clinical records and interviews with facility staff. Resident R164 was admitted on December 9, 2024, and discharged on December 18, 2024, but the discharge summary was not completed within the mandated timeframe. Similarly, Resident R162, admitted on November 26, 2013, and discharged to the hospital on January 13, 2025, also lacked a timely discharge summary. Interviews with the Nursing Home Administrator confirmed these findings, indicating a lapse in adherence to the facility's policy on discharge documentation.
Plan Of Correction
1. R164 is discharged and record closed. R162 is discharged and record closed. 2. All discharges from March 20 will be audited to ensure 30 day discharge note from attending physician has been completed. 3. Education to all attendings that a discharge summary must be completed within 30 days completed. 4. Random audits by the Administrator/designee of up to 5 residents to ensure that the attending has completed a 30 days discharge note once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Timely Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary within the required 30 days following the death of a resident. Specifically, the clinical record of a resident who was admitted on June 28, 2021, and died on November 13, 2024, was reviewed. It was found that the discharge summary was not completed until January 31, 2025, which exceeded the 30-day requirement. This deficiency was confirmed during an interview with the facility's Nursing Home Administrator on January 31, 2025.
Plan Of Correction
Step 1 Discharge Summary for resident R200 was completed. Step 2 The facility completed an audit of discharge records for the last 30 days to ensure that a discharge summary was completed. Step 3 Medical record staff and physician educated on the requirement to ensure that a discharge summary is completed within 30 days of discharge. Step 4 Medical record Director/designee will audit discharged records weekly x 4 monthly x 2 to ensure that a discharge summary was completed. Findings will be reviewed during QAPI.
Failure to Complete Discharge Summary Within 30 Days
Penalty
Summary
The facility failed to complete a discharge summary within 30 days of a resident's death, as required by regulation. A closed clinical record review for a resident revealed that nursing documentation noted the resident was without pulse or respirations and was pronounced deceased. However, the review also showed that no discharge summary, including the final diagnosis and cause of death, was completed within the required timeframe. This deficiency was identified during a closed clinical record review and confirmed through staff interviews.
Plan Of Correction
1. Facility cannot retroactively provide resident 100's discharge summary. 2. Medical records director/designee conducted an audit of the last 2 weeks of discharges to verify discharge summaries have been completed. 3. Providers will be re-educated on providing discharge summaries. 4. DON/designee will audit discharges to verify they have completed discharge summaries weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
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