Failure to Include Discharge Planning in Resident Care Plan
Penalty
Summary
The facility failed to ensure that discharge planning was incorporated into the care plan for one of five residents reviewed. According to facility policy, every resident should have an individualized discharge plan that begins at admission and is included in the comprehensive care plan. Clinical record review showed that a resident with diagnoses of hip fracture, hypertension, and cerebrovascular disease expressed a desire to return home with home services after completing physical therapy. However, there was no documented evidence in the clinical record that discharge planning or a discharge care plan had been developed for this resident. This deficiency was confirmed by the Director of Nursing and the Registered Nurse Assessment Coordinator during staff interviews.