Failure to Document Discharge Planning in Resident Care Plan
Penalty
Summary
The facility failed to initiate and document a resident-specific discharge care plan during both the admission and quarterly review processes for one resident. The resident, who had a history of acute pulmonary edema, muscle weakness, anxiety disorder, type 2 diabetes mellitus, and bilateral primary osteoarthritis of the knee, required varying levels of assistance with activities of daily living, including transfers and toileting. Despite these needs and ongoing discussions about discharge, there was no evidence in the resident's care plan or Minimum Data Set (MDS) assessments that active discharge planning was occurring or documented. Interviews with facility staff, including a Licensed Vocational Nurse, Social Services assistant, MDS coordinator, and the Director of Nursing, confirmed that while discharge planning was discussed with the resident, it was not formally documented in the care plan during admission or quarterly review. The facility's policy required comprehensive care plans, including discharge planning, to be developed and updated based on assessments and changes in the resident's condition. The lack of documentation resulted in the absence of individualized discharge planning for the resident during transitions of care.