Failure to Revise Care Plan and Assist with Community Discharge Planning
Penalty
Summary
A deficiency was identified when the facility failed to revise a resident's comprehensive care plan to reflect her expressed desire to live in the community and did not provide adequate discharge planning assistance. The resident, who had multiple diagnoses including multiple sclerosis, diabetes, anxiety disorder, bipolar disorder, schizoaffective disorder, and major depression, was admitted with an initial care plan indicating long-term placement. Although the resident initially agreed to stay at the facility, she later communicated her wish to leave and live independently in an apartment, despite previous eviction issues. Documentation showed that after the resident expressed her intent to leave, the facility offered referrals to other facilities, which she declined, but did not explore or document other community-based options. There was no evidence in the care plan or nursing notes that her request to return to the community was addressed or that interventions were implemented to support her discharge goal. The facility's own policy required documentation of the resident's preferences and referrals to local contact agencies, but this was not done. Interviews with the social service designee and the resident's mother confirmed that the resident's preference for community living was not incorporated into her care plan, and no efforts were made to assist her in finding community options. The resident ultimately left the facility without a formal discharge plan, and her mother reported that the facility did not provide support for her daughter's goal to live outside the facility.