Failure in Individualized Discharge Planning
Penalty
Summary
The facility failed to provide individualized discharge planning for a resident, identified as Resident R1, who was admitted on 5/15/24. The resident's clinical record indicated diagnoses of anxiety disorder, depression, and psychoactive substance abuse. The care plan noted the resident's expectation to discharge back to the community after completing the care plan, with social services to assist as necessary. However, the clinical records lacked documentation of referrals or communication with other agencies for housing after discharge and did not include interviews with the resident regarding discharge planning. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Plan Of Correction
1. Resident R1 was interviewed by the social service team and IDT team members on their preference for discharge location. Resident R1 indicated they did not have a specific location they preferred at this time. In the meantime, social services indicated they would initiate the nursing home transitions program as a viable option for transition to the community, and in the event Resident R1 changed their mind, they would notify social services. 2. The Social Service Director or designee will audit resident admissions from the past 2 weeks to ensure resident discharge preference is documented on admission with a plan to follow up depending on the resident's clinical, therapeutic, and social status/ability. 3. The Administrator will re-inservice the Social Services Department to ensure resident discharge preference is documented on admission with a plan to follow up depending on the resident's clinical, therapeutic, and social status/ability. 4. The Social Services department will audit resident preference for discharge on admission for the next 2 weeks and follow up depending on the resident's clinical, therapeutic, and social status/ability. Audits will be shared with the QAPI committee to ensure continued compliance.