Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure a proper discharge planning process for Resident #105, who expressed a desire to return to their prior living situation. Despite the resident's goal to be discharged back to their apartment, the facility did not assist with discharge planning or provide updates on the status of their discharge goal. The facility's policies required collaboration with the resident to ensure a smooth transition of care, including resident education and participation in discharge planning, but these were not adhered to in this case. Resident #105 had a history of metabolic encephalopathy and repeated falls, and their Minimum Data Set assessments indicated a goal to return to the community. The resident was independent in most activities of daily living, as documented in therapy discharge summaries. However, there was no evidence of an interdisciplinary care plan meeting to discuss the resident's discharge potential and goals. Interviews with staff revealed a lack of communication and documentation regarding the resident's discharge plan, and the resident expressed concern about not being able to go home. Interviews with various staff members, including CNAs, LPNs, and the Director of Quality Management, highlighted a lack of awareness and involvement in the resident's discharge planning. The resident had been cut from therapy, which should have triggered a care plan meeting, but this did not occur. The resident's mental health and functionality were at risk due to the delay in discharge planning, and the resident was left without clear communication or a plan to return home, resulting in them slipping through the cracks of the facility's discharge process.
Plan Of Correction
Plan of Correction: Approved February 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #105 has met with the Social work department and a discharge plan is being developed with the residents input as well as the IDT. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A 100% audit of all residents wishing to discharge for an active discharge plan will be completed. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? IDT will be educated on the discharge planning policy and procedure. A discharge planning meeting will be scheduled upon admission. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? An audit will be conducted by the MDS Coordinator or representative assigned to confirm discharge planning meeting has occurred by the completion of the comprehensive MDS. The date for correction and the title of the person responsible for correction of each deficiency: MDS Coordinator.