Failure to Document Resident Choice in Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident was appropriately discharged in accordance with their needs and preferences. The resident, who had diagnoses including spondylosis, type 2 diabetes mellitus, hypothyroidism, and hypertension, was admitted with a care plan that required coordinated discharge planning to their home with family. The facility was responsible for assisting the resident and their support person in locating and coordinating post-discharge services, such as home health care, durable medical equipment, oxygen, prescriptions, and other support services. However, documentation revealed that the facility did not provide evidence that the resident was presented with options or assisted in choosing a post-acute care provider that best suited their goals, preferences, needs, and circumstances. Interviews with facility staff indicated that while a form existed for residents to select the facility's preferred home health agency, there was no documented evidence that the resident in question was given a choice or presented with alternative providers. Other residents had signed referral forms for the facility's home health agency, but some did not recall signing them, and the facility did not maintain a list of home health agency providers to offer as options. The Director of Nursing and the Administrator both acknowledged that documentation of discharge planning discussions and options provided was lacking or not consistently recorded in the resident's notes.