Failure to Update Discharge Plan Based on Resident's Stated Preferences
Penalty
Summary
The facility failed to develop and implement a discharge planning process that aligned with a resident's goals and preferences. According to the facility's own Discharge Planning Policy, discharge needs should be identified and a plan developed for each resident, with regular re-evaluation to update the plan as needed. In the case reviewed, a resident with congestive heart failure, who was cognitively intact as indicated by a BIMS score of 15, expressed a desire to be discharged home during both a care plan meeting and a resident council meeting. Despite these clear statements of intent, there was no documented follow-up or revision of the resident's discharge plan to reflect her current wishes. Clinical record review showed that the last nursing progress note regarding the resident's discharge plans and goals was several months prior, and the comprehensive care plan had not been updated to address the resident's expressed desire for discharge. The care plan continued to indicate a need for long-term care without evidence of individualized discharge planning or regular re-evaluation as required by policy. The Nursing Home Administrator confirmed the absence of a current discharge goal and plan for the resident, indicating a failure to update the discharge plan in response to the resident's stated preferences.