Failure to Ensure Adequate Discharge Planning and Follow-Up
Penalty
Summary
The facility failed to maintain an adequate discharge planning process to ensure a resident's preference for discharge was met. The resident, who had intact cognition and no behavioral or psychiatric issues, expressed a desire to move closer to family in a neighboring state. Although the care plan indicated that the resident and family were seeking a skilled nursing facility (SNF) in the desired area and that referrals had been initiated, there was a lack of documentation regarding where referrals were sent, updates on the status of those referrals, or outcomes from the MNchoice assessment. Progress notes showed some referrals and assessments were made, but did not include follow-up information or communication with the resident or family about the discharge process after certain dates. Interviews with staff revealed that there was no evidence of follow-up on discharge plans or referrals in the electronic medical record since the last care conference, despite the resident's ongoing wish to discharge. The social services director acknowledged the absence of follow-up, and the director of nursing stated that the expectation was for social services to remain involved and for resources to be set up for a safe discharge in a timely manner. The facility's own discharge planning policy required continuous evaluation and implementation of interventions to address discharge goals, which was not reflected in the documentation or actions taken for this resident.