Failure to Develop Individualized Discharge Plans
Penalty
Summary
The facility failed to evaluate and develop individualized discharge plans for three residents, R11, R34, and R46, upon admission and throughout their stay. Despite being cognitively intact and expressing their needs, these residents did not have documented discharge plans that aligned with their preferences. Resident R11 expressed a desire to transfer to another nursing home closer to his brother, but there was no documentation of assistance from the social worker after the initial request. Resident R34 wanted to return to the community closer to family, but no discharge care plan was established. Resident R46 desired to be discharged to the community with her cousin, but there was no follow-up documentation after an initial social service note. Additionally, Resident R46 was involved in a physical altercation with another resident, R81, which led to a consideration for transfer to a facility specializing in behavioral wellness. However, there was no documented update on this discharge plan. The lack of interdisciplinary care planning for discharge was confirmed by interviews with the director of nursing and social work staff. The facility's failure to adhere to its discharge policy and procedure resulted in unmet discharge planning needs for these residents.
Plan Of Correction
The facility has assessed and documented residents R11, R34, and R46 for placement and/or discharge goals. The facility will complete an audit of residents with a quarterly/annual review in the last 30 days to appropriately identify placement and/or discharge goals. The facility will monitor all residents' documentation and care plans identifying appropriate placement and/or discharge goals in the resident's health record and review at least quarterly at each care conference with the resident and/or resident representative. Social Worker / designee will complete a documentation and care plan audit for 8 residents, weekly x3 months. Findings will be reported to the QAPI committee.