Failure to Develop and Implement Discharge Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement discharge care plans for two of three sampled residents. For the first resident, who was admitted following surgery, there was no evidence in the medical record that a discharge care plan was created prior to their discharge. Interviews with the Social Service Director (SSD) and Director of Nursing (DON) confirmed that a discharge care plan should have been completed at admission, but was not present for this resident. The second resident, admitted with hemiplegia, was observed on the day of discharge without knowledge of their discharge destination. A review of this resident's medical record also revealed the absence of a discharge care plan. The SSD confirmed that a discharge care plan was not developed for this resident, despite facility policy requiring a baseline care plan within 48 hours of admission and a comprehensive, person-centered care plan to be implemented for each resident.