Failure to Involve Resident in Discharge Planning and Communication
Penalty
Summary
The facility failed to provide ongoing assistance and coordination, with resident involvement, in developing discharge goals and plans for discharge for one resident. The medical record showed that the resident was admitted with multiple diagnoses, including atrial fibrillation, venous insufficiency, major depressive disorder, hypertension, dysphagia, and a right artificial hip joint. The resident was cognitively intact, used a wheelchair, was independent with activities of daily living, and was at risk for pressure ulcers but had no skin breakdown. Initial assessments and quarterly reviews documented a discharge goal of returning home, and the resident had an apartment being held for this purpose. However, a nursing plan of care later documented the resident as a permanent placement, and a physical therapy discharge summary listed the discharge destination as LTC, with no documentation that the resident was informed of this change. Interviews revealed that the resident was not informed about the change in discharge plans and had limited contact with social services regarding discharge planning. The social worker, upon assuming the role, was told the resident was staying long-term, but later learned from the resident that he still intended to return to the community. The medical record lacked documentation of resident involvement or updates regarding discharge planning, and there were no further instructions to staff or evidence that the resident was informed about the recommendation for long-term placement.