Failure to Develop and Implement Person-Centered Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered discharge care plans for two residents during their stay, as identified through interviews and record reviews. One resident, admitted with Alzheimer's disease, was discharged to another facility for supervised care in a secured unit, but there was no documented evidence of a discharge care plan being created or followed. Similarly, another resident with encephalopathy was discharged to a board and care facility for a lower level of care, yet no discharge care plan was documented in the clinical record. Interviews with nursing staff and the Director of Nursing confirmed that discharge care plans are expected to be developed upon admission to ensure staff are aware of residents' discharge wishes and to facilitate coordinated, goal-oriented discharges. The absence of these care plans meant that staff were not informed of the residents' goals or wishes regarding discharge, and there was no organized or collaborative approach to preparing for their transitions. Facility policy requires comprehensive, person-centered, interdisciplinary care planning, but this was not followed in these cases.