Failure to Implement Individualized Discharge Plan
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for a resident, identified as Resident 3, who was admitted with a diagnosis of atrial fibrillation. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident expressed a desire to be discharged home. However, there was a significant gap in the documentation of discharge planning, with social service notes indicating the resident's wish to go home dated August 28, 2024, and the next note not appearing until November 18, 2024. This lack of documentation and follow-up resulted in no clear discharge plan being in place by the time of the survey ending January 31, 2025. The comprehensive care plan for the resident did not reflect any updates or revisions to address the resident's current discharge goals or long-term placement desires. During an interview, the Nursing Home Administrator confirmed the absence of documented evidence of a current discharge goal and plan for the resident. This oversight highlights a failure in the facility's discharge planning process, as it did not adequately address the resident's expressed wishes or ensure a timely and effective transition plan.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below. Resident 3 had their discharge plan revised, to reflect the resident's current desire for discharge. To identify other residents that have the potential to be affected, the Social Service Director / designee will review the short-term residents in-house to assure that an individualized discharge plan reflects the residents' current desire for discharge or long-term placement. To prevent this from re-occurring, Social Services will be re-educated to follow up on documentation noted in the medical record of a resident change related discharge planning to discharge home or remain long-term and the care plan will be updated to reflect the residents' wishes. To monitor and maintain compliance, the Social Service Director / designee will randomly review social service notes each week of five short term residents for documentation related to discharge planning and check that the care plan on discharge reflects the residents' current discharge plan as documented in the clinical notes. The audits will be completed weekly times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.