Resident Excluded from Discharge Planning Despite Retaining Decision-Making Rights
Penalty
Summary
The facility failed to ensure that a resident retained the right to participate in their own discharge planning process. The resident, who had a history of congestive heart failure and alcohol use disorder, was assessed as having moderate cognitive impairment but remained their own healthcare decision maker, as the Health Care Proxy had not been activated by the physician. Despite this, the facility conducted a discharge planning meeting with the resident's sibling and facility staff, without inviting or involving the resident. The medical record did not document any participation or input from the resident regarding the discharge plan. Interviews revealed that the resident was unaware of the discharge plan and expressed a desire to return home with siblings, while staff believed the plan was for discharge to an assisted living facility. The social worker involved in the discharge planning admitted that the resident was not invited to the meeting and that she mistakenly thought the Health Care Proxy had been invoked, leading to the sibling making decisions. The physician confirmed that the resident continued to make their own decisions, and the social worker later acknowledged the resident should have been included in the discharge planning process.