Deficiencies in Discharge Planning and Urinary Drainage Bag Management
Penalty
Summary
The facility failed to develop and implement a discharge care plan for a resident who was discharged home with family. The resident had a clinical diagnosis of a displaced tri-malleolar fracture of the right lower extremity and required orthopedic aftercare. Despite the resident's choice to be discharged, the facility did not create a discharge care plan, which is a requirement under the comprehensive care plan statute. The MDS Coordinator acknowledged the absence of a discharge care plan for the resident. Additionally, the facility did not ensure the security of urinary drainage bags for two residents. One resident was observed carrying their drainage bag in their hand and placing it on the floor, while another resident had their drainage bag tubing caught on the wheelchair's wheels. These practices increased the risk of urological complications if the bags were unintentionally pulled, leading to potential dislodgement. Staff members, including an LPN and the DON, were aware of these issues but did not consistently address them. The facility's policies and procedures require the development of a comprehensive care plan within seven days of a resident's assessment, which includes measurable objectives and timetables to meet the resident's needs. However, the facility failed to adhere to these policies, resulting in deficiencies related to the lack of a discharge care plan and the improper management of urinary drainage bags.
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.