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F0656
D

Failure to Develop Discharge Care Plan

El Cajon, California Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a discharge care plan for one resident who was admitted with heart failure, as evidenced by a review of the resident's medical record showing no discharge care plan was created prior to the resident's discharge. Interviews with the Social Service Director and the Director of Nursing confirmed that the responsibility for creating the discharge care plan was missed, despite facility policy requiring an individualized discharge plan to be initiated at admission and included in the comprehensive care plan. The absence of a discharge care plan was identified during a record review and staff interviews, with both the Social Service Director and Director of Nursing acknowledging the oversight.

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