Failure in Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide adequate discharge planning for a resident, identified as Resident R1, who was admitted with diagnoses including opioid abuse, alcohol abuse, other psychoactive substance abuse, and cerebral infarction. The resident was cognitively intact as per a Brief Interview for Mental Status assessment. However, on a specific date, Resident R1 left the facility without authorization, and the facility did not have a discharge order from the physician for this resident. The facility's policy on discharging residents requires consultation with the resident about the discharge process, assessment and documentation of the resident's condition, and preparation of necessary equipment and supplies. However, these steps were not followed for Resident R1, as evidenced by the lack of documentation regarding the resident's discharge needs and the absence of a physician's order for discharge. Additionally, the facility did not have information on the resident's whereabouts after the unauthorized leave of absence. Interviews with staff revealed that the discharge Minimum Data Set (MDS) assessment was completed after the resident's elopement, with the assumption that the resident would not return. The Director of Nursing confirmed that the facility failed to complete a timely and safe discharge for Resident R1, indicating a lapse in the discharge planning process as required by regulations.
Plan Of Correction
F-660 Discharge Planning 1. A discharge order was obtained for R1. 2. Resident discharges will be reviewed at the next Clinical Meeting to ensure compliance with the discharge process. 3. The IDT Team will be educated on the discharge policy and procedure to include all items needed for discharge. The Director of Nursing or designee will audit all discharges weekly for 2 weeks and then monthly for 2 months to ensure discharges are completed per policy. 4. A summary of the results of the audits will be reviewed by the Director of Nursing or designee in the Monthly QAPI meeting for 2 months.