Failure to Re-Evaluate and Document Discharge Planning for Resident
Penalty
Summary
The facility failed to regularly re-evaluate, refer, and document referrals to local contact agencies for discharge planning and assessment for one resident. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and osteoarthritis, was found to have intact cognition and required only supervision or minimal assistance with activities of daily living. Despite being assessed as having good discharge potential and expressing a desire to be discharged to an assisted living facility, the resident reported not receiving updates or assistance regarding discharge planning after an initial referral discussion with a previous social worker. The resident stated he had not been informed of any progress or timeline for discharge and was concerned about having nowhere to go if the facility did not assist him. Staff interviews revealed that the social services department had experienced significant turnover, with most social workers having left and a new team recently starting. The Social Services Director confirmed that there was no record of a referral for discharge assessment in the facility's referral tool, despite the resident's eligibility and readiness for community discharge. The resident's care plan and assessments had not been updated as required, and there was a lack of ongoing communication and documentation regarding discharge planning, contrary to facility policy and standard practice.