Failure in Discharge Planning for Resident Requesting Transfer
Summary
The facility failed to develop and implement an effective discharge planning process for a cognitively intact resident who requested a transfer to another nursing facility. The resident, diagnosed with Paranoid schizophrenia and Depression, expressed a desire to move to a facility in Suffolk County. Despite a Physician's Order and recommendations from Psychiatry Consultations for Social Services to discuss nursing home options with the resident, there was no documented evidence that these discussions took place. The resident's discharge goals were not addressed, and the section of the Minimum Data Set (MDS) assessment related to the resident's overall goal for discharge was left blank. Interviews with facility staff revealed a lack of communication and responsibility regarding the discharge planning process. The resident's assigned Social Worker did not meet with the resident to discuss discharge options, citing the resident's occasional confusion as a reason. The Discharge Planner was unaware of the Physician's Order and did not recall any discussions with the Social Worker about the resident's request. The Director of Social Services acknowledged that the Social Worker should have engaged with the resident to understand their reasons for wanting a transfer and to improve their experience at the facility. The Administrator confirmed that the resident's right to participate in care plan meetings was not upheld, and the Physician's Order was not followed.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 F 660 – Discharge Planning Process The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) A discharge planning meeting was held on 12/18/2024 with Resident #93 to address his request to be transferred to another facility. Resident is scheduled for discharge on 01/15/2025. b) Resident #93 was seen by the Social Worker with no psychological harm noted from this deficient practice. c) The Social Worker who failed to initiate the discharge planning process for Resident #93 received educational disciplinary action on 01/13/2025. B) Identification of other Residents having the potential to be affected by the deficient practice: All cognitively intact residents without family or legal representative are at risk for this deficiency. The Director of Social Work will compile a list of all Residents with a BIMS score of 13 – 15. Utilizing this list, the Social Worker will create an audit tool and interview Residents to determine if they had expressed a desire to be discharged to another facility. Any residents found to have this request will have a discharge planning meeting to determine the feasibility of facilitating the discharge. The Medical Director will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the past 6 months, to ensure that all recommendations made are reviewed and implemented if applicable; or that there is documented evidence if the physician disagreed with the recommendation. Any negative findings will be immediately corrected. C) Systemic Changes to ensure the deficient practice will not recur: The “Discharge Summary and Plan” policy and procedure with a review date of 01/2025 was reviewed and found to be in compliance. a) All onsite and offsite attending medical providers will be re-educated on the procedure of: a. Documenting their agreement with a consultant’s recommendation and implementing the physician’s order; or b. Documenting their disagreement and documenting the reason for disagreement. All Social Workers responsible for the enforcement of the “Discharge and Summary Plan” policy and procedure will receive re-education regarding this policy. Education will also emphasize the inclusion of residents in all care plan meeting discussions and documentation of discharge meetings held. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA – Monitor of the deficient practice: The Director of Social Work/Designee will have the responsibility of interviewing 10% of the population of Residents with a BIMS score of 13-15, to ensure their request for discharge (if applicable) was addressed by the assigned Social Worker. Any negative findings will be immediately corrected and results of findings will be reported to the QAPI committee quarterly. This audit will be conducted weekly x 3 months, then monthly x one year. The Director of Social Work is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Penalty
A resident with moderate cognitive impairment and multiple medical conditions expressed a desire to move to assisted living, but the care plan continued to reflect a long-term stay in the facility. Although the social worker was aware of the resident's goal and began working on placement, the care plan was not updated to match the resident's current wishes, as confirmed by both the SW and DON.
A resident with intact cognition and good discharge potential was not regularly re-evaluated, referred, or provided documented referrals to local agencies for discharge planning. Despite being eligible and expressing a desire to move to assisted living, the resident received no updates or assistance after an initial referral discussion, and staff confirmed there was no record of a formal referral or updated care plan, due in part to recent staff turnover in social services.
A resident with multiple fractures and significant care needs was discharged without a comprehensive care plan, proper coordination with outside providers, or complete discharge instructions. The facility did not ensure necessary medical equipment was ordered or that referrals and follow-up care were arranged, resulting in an incomplete and inadequate discharge process.
A resident with diabetes was discharged without receiving necessary education on insulin administration, diabetes management, or use of a glucometer, and was also sent home without prescribed medications and supplies due to a lack of medication reconciliation and communication among staff.
A resident with a history of a leg fracture and diabetes was discharged after improvement, but required post-discharge follow-up calls were not documented in the medical record. Interviews with the SSD and DON confirmed that facility policy mandates follow-up calls within 72 hours and again between 14-28 days post-discharge, but there was no evidence these were completed or recorded for the resident.
A resident with multiple fractures and a traumatic pneumothorax was discharged without the home health services specified in their care plan and physician orders. Although referrals to home health agencies were made, none accepted the resident, and there was no documentation confirming that services were scheduled. The resident's spouse reported not being contacted by any agency, and staff confirmed the discharge plan was not implemented as required.
Failure to Update Discharge Plan to Reflect Resident's Goals
Penalty
Summary
The facility failed to develop a discharge plan that reflected a resident's goals and needs for one resident reviewed for discharge planning. The resident, who had diagnoses including depression, diverticulitis, and obstructive and reflux uropathy, was assessed as having moderate cognitive impairment. The resident's care plan indicated a long-term stay with the goal of remaining in the nursing home, despite the resident expressing a desire to move to assisted living. The care plan interventions included discussing feelings and goals for placement as needed, involving social services, and arranging for discharge if needed, but did not actively reflect the resident's stated goal of transitioning to assisted living. Interviews revealed that the resident had communicated his wish to move to assisted living to the social worker, who became aware of this goal in mid-January after being contacted by an assisted living facility. The social worker acknowledged working with the resident and his representative on enrolling in a managed care organization to facilitate placement. However, the care plan was not updated to reflect the resident's current discharge goal, despite both the social worker and the director of nursing agreeing that the care plan should have been revised as soon as staff became aware of the change in the resident's goals.
Failure to Re-Evaluate and Document Discharge Planning for Resident
Penalty
Summary
The facility failed to regularly re-evaluate, refer, and document referrals to local contact agencies for discharge planning and assessment for one resident. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and osteoarthritis, was found to have intact cognition and required only supervision or minimal assistance with activities of daily living. Despite being assessed as having good discharge potential and expressing a desire to be discharged to an assisted living facility, the resident reported not receiving updates or assistance regarding discharge planning after an initial referral discussion with a previous social worker. The resident stated he had not been informed of any progress or timeline for discharge and was concerned about having nowhere to go if the facility did not assist him. Staff interviews revealed that the social services department had experienced significant turnover, with most social workers having left and a new team recently starting. The Social Services Director confirmed that there was no record of a referral for discharge assessment in the facility's referral tool, despite the resident's eligibility and readiness for community discharge. The resident's care plan and assessments had not been updated as required, and there was a lack of ongoing communication and documentation regarding discharge planning, contrary to facility policy and standard practice.
Failure to Implement Effective Discharge Planning and Coordination
Penalty
Summary
The facility failed to implement an effective discharge process for Resident #394, as evidenced by several deficiencies in planning and coordination. The resident, who was admitted following multiple fractures and required maximal to moderate assistance with activities of daily living, was discharged home after insurance coverage ended. Despite the resident's complex needs, including non-weight-bearing status, limited mobility, incontinence, and the need for intermittent self-catheterization, the facility did not develop a comprehensive discharge care plan, coordinate referrals to outside providers, or order the recommended medical equipment. Additionally, the discharge packet was incomplete, lacking a home medication list and other essential information at the time of discharge. The record review and staff interview confirmed that only an initial care conference was held, with no further documented planning or coordination for the resident's transition to home. The discharge paperwork was initiated late and was incomplete, and there was no evidence of proper coordination with home health agencies or vendors for necessary services and equipment. The physician's discharge summary outlined ongoing care needs and follow-up appointments, but the facility did not ensure these were addressed in the discharge process.
Failure to Provide Discharge Education and Medication Reconciliation for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, among other diagnoses, was discharged from the facility without receiving necessary education on diabetes management, specifically regarding the use of newly prescribed Insulin Lispro, insulin sliding scale, and self-injection techniques. The clinical record and facility documentation showed that the resident did not receive teaching or training on diabetes care, use of a glucometer, or insulin administration during their stay, despite care plans and physician orders indicating these needs. Nursing notes failed to document any education provided on these critical aspects of diabetes self-management prior to discharge. Additionally, the facility failed to perform proper medication reconciliation before the resident's discharge. The discharge summary and medication list indicated that the resident was to continue with Insulin Lispro and gabapentin, but these medications and necessary supplies were not provided to the resident upon discharge. Communication breakdowns between nursing staff and the prescribing provider led to the assumption that the resident had all required medications, resulting in the omission of new prescriptions and supplies needed for safe transition home. Interviews with facility staff confirmed that the resident was discharged without the prescribed medications and without the required education on their use. The facility's own discharge planning policy required reconciliation of all pre- and post-discharge medications and provision of education, but these steps were not completed. The deficiency was identified after the home care nurse reported the missing medications and lack of discharge teaching, prompting an internal investigation that confirmed the failures in discharge planning and education.
Failure to Document Post-Discharge Follow-Up
Penalty
Summary
The facility failed to ensure that a post-discharge follow-up was conducted and documented in the medical record for one resident. The resident, who had a history of a left tibia fracture and type 2 diabetes mellitus, was admitted to the facility and later discharged after his health improved. Documentation review showed that there was no evidence of a follow-up call or contact with the resident after discharge, as required by facility policy. The Social Service Director confirmed that follow-up calls should be made within 72 hours post-discharge and that records of such calls are maintained, but was unable to confirm whether the case manager completed this for the resident in question. Further interviews with the Director of Nursing revealed that both social services and case management are responsible for conducting and documenting follow-up calls at specific intervals after discharge. Review of facility policies confirmed the requirement for timely follow-up calls and accurate documentation in the medical record. However, there was no documentation indicating that the required post-discharge follow-up was completed for the resident, resulting in a deficiency related to discharge planning and documentation.
Failure to Provide Discharge Planning Focused on Resident's Needs
Penalty
Summary
The facility failed to provide adequate discharge planning for one resident, as required by regulation. The resident was admitted with multiple serious injuries, including fractures to the ribs, right tibia, cervical spine, and a traumatic pneumothorax. The clinical record indicated that the resident was to be discharged with home health services, including PT, OT, RN, and aide support, as per physician orders and social services assessments. However, the discharge plan documentation showed that the resident was discharged without these home health services. Facility records revealed that referrals were made to home health agencies, but these agencies were unable to accept the resident for services. There was no documentation in the progress notes confirming that home health services were scheduled or provided. Additionally, the resident's spouse contacted the facility to report that they had not been contacted by any home health agency. During staff interviews, it was confirmed that the facility did not implement the required discharge plan for the resident.
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