Failure in Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide adequate discharge planning for Resident R46, as evidenced by the lack of discharge instructions, inventory, or medication reconciliation in the resident's progress notes. Resident R46 was admitted on February 7, 2025, with diagnoses including muscle wasting, anemia, and failure to thrive. The Minimum Data Set (MDS) assessment dated February 13, 2025, and physician orders dated March 9, 2025, indicated that the resident was to be discharged to home with home health services. However, upon review of the progress notes from March 2025, there was no documentation of discharge instructions or any indication that the resident had been discharged. This deficiency was confirmed during an interview with the Director of Nursing on March 13, 2025, who acknowledged that the facility did not complete the necessary discharge documentation for Resident R46 as required by the discharge planning process.
Plan Of Correction
Unable to correct R46. Moving forward, the facility will ensure discharge planning is completed that focuses on resident goals. To identify other residents that have the potential to be affected, the Director of Nursing (DON)/designee reviewed pending discharges to ensure discharge documentation is completed as required. Corrections will be made as needed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated licensed nursing staff on the regulatory requirements of F660. To monitor and maintain ongoing compliance, the DON/designee will audit discharge documentation weekly x4 and monthly x2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.