Failure to Include Discharge Planning in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans that included measurable objectives and timeframes for four out of ten residents reviewed. Specifically, the care plans did not address discharge goals, objectives, and interventions for these residents, despite their varied and complex medical conditions. For example, one resident with acute kidney failure, dementia, and impaired mobility had a care plan that omitted discharge planning, even though she was moderately cognitively impaired and unable to recall details about her discharge or personal belongings. Another resident, admitted for short-term skilled care following hospitalization, had diagnoses including muscle wasting, prostate cancer, and cardiac issues. Although he was cognitively intact and aware of his short-term therapy goals, his care plan did not include discharge objectives or interventions. Similarly, two other residents with significant medical histories, such as end-stage renal disease, COPD, stroke, and hemiparesis, also had care plans lacking discharge planning components, despite their imminent plans to return home with family support. Interviews with facility staff, including the ADON, DON, and ADM, confirmed that care plans were not consistently updated to reflect discharge planning, with some staff relying on separate discharge assessments or planning by other disciplines. The facility was unable to provide a care plan policy when requested. Federal guidelines require that comprehensive care plans include measurable objectives, timeframes, and discharge planning in consultation with the resident and their representatives, which was not met in these cases.