Failure to Involve Resident in Discharge Planning
Penalty
Summary
The facility failed to follow its policy and procedures for discharge planning for one resident. The resident, who had diagnoses including diabetes mellitus, hypertension, atrial fibrillation, hyperlipidemia, and chronic kidney disease, was assessed as having the capacity to understand and make decisions, with intact cognitive skills for daily decisions. The resident was independent in bed mobility and required varying levels of assistance with other activities of daily living. The care plan for discharge planning included interventions such as providing written and verbal instructions at the patient/family's level of understanding and reviewing and discussing the discharge plan with the resident and family as appropriate. Despite these requirements, a review of the case manager's progress notes revealed that only the resident's family member had been contacted regarding discharge planning, with no documentation indicating that the resident was informed or involved in the discharge plan over the previous three months. The case manager confirmed there was no evidence in the notes to show the resident's involvement. Facility policies reviewed stated that residents have the right to be informed of and participate in their care planning and treatment, and that post-discharge plans should be developed with the assistance of the resident and family. This lack of documentation and involvement constituted a failure to ensure the resident was properly informed and involved in their discharge plan.