The Director of Nursing admitted during an October 1 interview that she wasn't aware Resident #1 had left without a discharge summary. She acknowledged the nursing team should follow up to ensure the summaries get completed but said there was "no potential risk to the resident" from the missing documentation.
Federal inspectors found the facility violated requirements for proper discharge planning and documentation during their November 20 complaint investigation.
The Administrator confirmed during a separate interview that residents should receive both a discharge summary and a physician discharge summary when leaving the facility. He said the expectation was for discharge summaries to be "developed and completed" by the nursing team.
The facility's own Discharge/Transfer policy, dated April 24, 2024, outlines specific requirements for resident departures. The policy states residents will be discharged by order of their attending physician and requires staff to notify the resident, their legal representative, or interested family members while documenting the discharge.
The policy also mandates written discharge instructions for residents going to lower levels of care, delivered "in a language they can understand" and documented in the medical record. Staff are supposed to use the electronic health record system's discharge instructions feature for residents moving to equal or lower care settings.
But the nursing team didn't follow these procedures for at least one resident who left the facility.
The Director of Nursing told inspectors the discharge summary should be completed by the nursing team when residents discharge. She said under the facility's previous system, discharge summaries were supposed to be finished within 10 days of a resident's departure.
Her statement that missing discharge summaries pose no risk to residents contradicts the purpose of the documentation, which is designed to ensure continuity of care when patients transfer between healthcare settings.
The Administrator's interview revealed he understood the facility's obligations. He clearly stated that both types of discharge summaries should be completed when residents leave Williamsburg Village Healthcare Campus.
Yet the system failed for Resident #1, who departed without the required paperwork.
Federal regulations require nursing homes to develop comprehensive discharge plans that identify post-discharge goals and include specific instructions for ongoing care. The discharge summary serves as a critical communication tool between the nursing home and the resident's next healthcare provider or family caregivers.
Without proper discharge documentation, receiving healthcare providers lack essential information about the resident's condition, medications, treatments, and care needs during their nursing home stay. This gap can lead to medication errors, missed treatments, or inadequate monitoring of ongoing health conditions.
The facility's electronic health record system includes specific pathways for discharge documentation, suggesting the tools exist for staff to complete the required summaries. The policy clearly outlines when and how to use these systems based on where residents are going after discharge.
The Director of Nursing's lack of awareness about the missing documentation suggests inadequate oversight of the discharge process. Her role includes ensuring nursing staff complete required documentation before residents leave the facility.
The Administrator's acknowledgment that discharge summaries should be completed indicates leadership understood the requirements but failed to implement systems ensuring compliance.
The facility's policy requires notification of family members or legal representatives about discharges, along with documentation of these communications. This process helps ensure someone will continue monitoring the resident's care needs after they leave the nursing home.
For residents discharged to lower levels of care, the policy specifically requires written instructions in understandable language. These instructions typically include medication schedules, dietary restrictions, follow-up appointments, and warning signs requiring medical attention.
The inspection found the facility's documentation failures affected few residents and caused minimal harm. But the violation represents a breakdown in basic discharge procedures designed to protect residents during vulnerable care transitions.
Federal inspectors classified this as a minimal harm violation affecting few residents, but the failure to complete required discharge documentation leaves gaps in the care continuum that could affect resident safety and wellbeing after they leave the facility.
The nursing team's failure to follow established discharge procedures despite clear policies and electronic systems designed to support the process raises questions about staff training and supervision of documentation requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Williamsburg Village Healthcare Campus from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Williamsburg Village Healthcare Campus
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