Failure to Develop and Implement Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered discharge care plans for three residents who had expressed goals to discharge to the community. Review of the Minimum Data Set (MDS), Care Area Assessment (CAA), and care conference notes for these residents confirmed that their discharge goals were documented, but the corresponding care plans did not include individualized discharge planning. The facility's policy and the Long-Term Care Resident Assessment Instrument (RAI) User's Manual require that discharge care plans be completed within seven days of the CAA, incorporating the resident's goals, preferences, and needs. Interviews with the Director of Nursing and Social Service Director revealed that the expected process was to include a discharge plan of care as part of the comprehensive care plan upon admission and after the comprehensive MDS was completed. However, record reviews and staff interviews confirmed that no such discharge care plans were present for the three residents in question, despite their stated goals and the facility's policy. The Executive Director also confirmed that the expectation was for discharge care plans to be completed per policy.