Failure to Develop and Document Discharge Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure that the discharge needs of a resident were identified and that an appropriate discharge plan was created. The resident, who had a complex medical history including a recent surgical amputation, acute osteomyelitis, cellulitis, morbid obesity, COPD, muscle weakness, unsteadiness, a Stage 4 pressure ulcer, venous insufficiency, peripheral vascular disease, and hypertension, required substantial to maximum assistance with activities of daily living. Despite her cognitive intactness and clear communication of her desire to return to the community, the facility did not document a comprehensive discharge plan or progress notes addressing her needs and preferences for discharge. The resident expressed significant concerns about her ability to live independently, including financial limitations, housing challenges, and the need for her support animal. She reported that no one at the facility was assisting her with discharge arrangements, and she was not provided with information about when Medicare coverage would end. The resident also stated that she would leave the facility against medical advice if necessary, as she could not afford to remain once Medicare stopped paying. She indicated that her previous living situation required repairs and that she faced barriers to public housing due to her criminal record and the presence of her service animal. Interviews with facility staff confirmed that discharge planning documentation was lacking. The social services staff member responsible for discharge planning acknowledged that there were no social service admission notes, progress notes, or a documented discharge plan in the resident's record. The administrator confirmed that discharge planning should begin at admission and be updated regularly, but was unaware that this had not occurred for the resident. The facility's discharge policy did not address the discharge planning process, contributing to the lack of appropriate planning and documentation.