Failure to Develop Comprehensive Care and Discharge Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required. For one resident admitted with hypertension, a pancreatic disorder, and a colostomy, the medical record showed that although the resident was cognitively intact and had a goal to return to the community, there was no active discharge plan, no referrals, and the local contact agency was unknown. The resident was routinely assessed for pain and received Tylenol for mild to moderate pain, but there was no evidence of a comprehensive pain care plan or a discharge care plan documented in the record. Similarly, another resident admitted with cirrhosis of the liver, diabetes mellitus, diverticulitis, and a colostomy was also cognitively intact and had a goal to return to the community. However, there was no active discharge plan, no referrals, and the local contact agency was unknown. The medical record did not contain evidence that a discharge plan of care had been developed for this resident. These findings were confirmed by interview with the Assistant Director of Nursing.