Failure to Provide Patient-Centered Discharge Planning and Communication
Penalty
Summary
The facility failed to ensure that discharge planning was patient-centered and involved both the resident and their representatives, as required by policy. For two residents reviewed, there was no evidence that the interdisciplinary team developed or documented a discharge plan that addressed the residents' goals, needs, or referrals to local agencies. Additionally, there was a lack of direct communication with the residents and their families regarding the discharge process, timeline, and preparation, despite facility policy requiring such involvement and documentation at least twenty-four hours prior to discharge. One resident, who was cognitively intact, and their family reported not receiving any information about discharge planning throughout the stay. The resident repeatedly asked staff for updates but was only informed of the discharge on the day it was to occur, leaving insufficient time to arrange transportation. Documentation in the electronic health record did not show any follow-up or involvement of the resident or family in the discharge planning process after an initial note, nor did it reflect any multidisciplinary team discussions or communication about the discharge timeline. Another resident, who was moderately cognitively impaired, also lacked documented discharge planning or communication with the family. The care plan indicated a need for 24/7 care at home, but there was no evidence that the discharge plan was reviewed or updated as the resident's cognitive status declined. Staff interviews confirmed that there was no documentation of communication with the resident or family, no record of team discussions, and no evidence that the family was prepared or received caregiver training prior to discharge.