Failure to Develop Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement a discharge care plan for a resident, which was identified during a survey. The resident was admitted with a diagnosis of a displaced trimalleolar fracture of the right lower extremity and was expected to be discharged home with family. Despite the resident's choice to be discharged and the absence of any medical equipment or home health requests, the facility did not create a discharge care plan. The resident's clinical records indicated that they were independent in some activities of daily living, such as eating and personal hygiene, but required assistance with others, like bathing and dressing. The facility's records showed that the resident was given a 30-day notice to vacate due to an unpaid bill, yet there was no evidence of a discharge care plan being developed to facilitate the transition home. Interviews with facility staff revealed a lack of clarity regarding responsibilities for care plan development. The Social Services Director stated that they were not responsible for care plans, while the MDS Coordinator acknowledged the absence of a discharge care plan for the resident. This oversight was contrary to the facility's policy, which mandates the development of a comprehensive care plan within seven days of a resident's comprehensive assessment.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 was discharged home. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the MDS Coordinator/Social Service Director/designee of current residents to ensure a discharge care plan is developed within 48 hours of admission/re-admission to be completed by. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; MDS Coordinator/Social Service Director re-educated by the Chief Clinical Reimbursement Officer on the components of this regulation and to ensure residents have a discharge care plan developed within 48 hours of admission/re-admission to be completed by. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; MDS Coordinator/Social Service Director/designee to conduct ongoing quality monitoring through morning clinical meeting to ensure a discharge care plan is developed within 48 hours of admission/re-admission 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.