Failure to Provide Person-Centered Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered discharge care plans for five residents reviewed. Each resident's care plan related to discharge planning was found to be nearly identical, lacking individualized information about specific discharge plans, goals, or interventions tailored to the resident's needs and preferences. For example, one resident with multiple medical diagnoses, including atrial fibrillation and deep vein thrombosis, had a care plan that only generically stated support for a short-term stay and assistance with referrals, without any specific discharge planning details. Interviews with residents and their representatives revealed a lack of communication and understanding regarding discharge plans, with some stating they had not been informed or involved in the process, and no social worker had discussed discharge planning with them. Further review with facility staff confirmed that a template was used for all residents' discharge care plans, resulting in no meaningful differences between individual plans. The social worker acknowledged that the care plans did not reflect resident-specific information and that notes, rather than the care plan itself, were used to document differences in resident situations. The facility's own policies require comprehensive, person-centered care plans with measurable objectives and timetables, including discharge plans and resident preferences, but these requirements were not met in practice for the residents reviewed.