Failure to Ensure Proper Discharge Planning for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident with severe cognitive impairment due to dementia and no family or surrogate decision-maker. The resident was admitted with dementia and had a BIMS score of 2, indicating severe cognitive impairment. The medical record showed that the resident was under a bioethics interdisciplinary team (IDT) and could not make medical decisions. Although a public resident representative met with the Social Service Director (SSD) to discuss criteria for a public representative, there was no documented evidence of a plan for conservatorship or that IDT meetings were conducted to address the resident's discharge needs, goals, or the appropriateness of the assisted living facility selected for discharge. The SSD documented the resident's discharge to an assisted living facility without evidence of how the decision was made, who authorized it, or whether the facility could meet the resident's dementia care needs. Interviews with the DON and SSD confirmed that no IDT meeting or third-party agency decision occurred prior to discharge, and the resident had no family member to assist in decision-making. The facility's policy required the care planning/interdisciplinary team to develop the discharge plan with the assistance of the resident and representative, but this process was not followed in this case.