Failure to Develop and Implement Timely Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans related to resident discharges for two of three residents reviewed. For one resident with chronic kidney disease and a responsible party, the discharge care plan was created by the Social Service Director on the day of discharge, rather than at admission as required. The resident had a moderately impaired cognitive score, and the discharge was to an assisted living facility via medical transport. The care plan listed interventions such as establishing a pre-discharge plan and coordinating discharge, but was not developed in a timely manner. For another resident with pneumonia and intact cognition, there was no documented evidence that a discharge care plan had been developed or implemented prior to discharge to an assisted living facility. Interviews with the DON and staff confirmed that discharge care plans should be developed at admission to allow for collaboration and preparation, and that the absence or late development of such plans could result in disorganized or unsafe discharges. The facility's policy also stated that discharge planning should begin at admission and be documented by social services.