Failure in Discharge Planning for Resident Requesting Transfer
Penalty
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