Failure to Develop and Communicate Effective Discharge Plan
Penalty
Summary
The facility failed to develop an effective discharge plan that ensured a resident's discharge goals were identified and addressed. The resident, who had hemiplegia, was informed by the Social Service Director (SSD) only one day prior to discharge that he would be leaving the facility. Despite expressing concerns regarding finances and the need for a wheelchair, the resident felt that the SSD did not listen or address these issues. The resident was also unaware of his discharge destination and had to contact family members himself to inform them of the impending discharge. Staff interviews revealed a lack of communication and preparation for the discharge. The Certified Nursing Assistant (CNA) was not informed of the discharge by the licensed nurse, learning about it from another resident instead, and had to hurriedly gather the resident's belongings. The licensed nurse was also unaware of the discharge until reviewing the medical record, which showed that the SSD had scheduled the discharge and arranged transport without a care plan or physician's order. The SSD acknowledged that a discharge care plan should have been created and that the resident's preferences were not considered. The facility's policy requires advance preparation and a post-discharge plan, which was not followed in this case.