Failure to Update Care Plan for Resident's Discharge Preferences
Penalty
Summary
The facility failed to maintain an up-to-date comprehensive care plan for a resident who was reviewed for discharge planning. The resident, who had intact cognition but experienced hallucinations, delusions, and fluctuating disorganized thinking, was independent with all activities of daily living. Despite multiple documented expressions of the desire to move out of the facility and pursue alternative living arrangements, such as assisted living or independent living, the resident's care plan was not updated to reflect these preferences. The care plan continued to state that the resident wished to remain in the facility and only wanted to be asked about discharge plans annually, with the last revision not reflecting the resident's ongoing requests for discharge. Progress notes and interviews with staff confirmed that the resident repeatedly communicated her wish to leave the facility, and assessments for relocation services were initiated. However, the care plan did not document these changes in the resident's goals or preferences. Staff interviews further revealed a lack of awareness or clarity regarding the resident's discharge plans, and both the assistant director of nursing and the social worker acknowledged that the care plan should have been updated to reflect the resident's expressed wishes. The facility's own policy required care plans to be regularly reviewed and updated to reflect changes in condition or preferences, which was not followed in this case.