Failure to Update Discharge Plan to Reflect Resident's Goals
Penalty
Summary
The facility failed to develop a discharge plan that reflected a resident's goals and needs for one resident reviewed for discharge planning. The resident, who had diagnoses including depression, diverticulitis, and obstructive and reflux uropathy, was assessed as having moderate cognitive impairment. The resident's care plan indicated a long-term stay with the goal of remaining in the nursing home, despite the resident expressing a desire to move to assisted living. The care plan interventions included discussing feelings and goals for placement as needed, involving social services, and arranging for discharge if needed, but did not actively reflect the resident's stated goal of transitioning to assisted living. Interviews revealed that the resident had communicated his wish to move to assisted living to the social worker, who became aware of this goal in mid-January after being contacted by an assisted living facility. The social worker acknowledged working with the resident and his representative on enrolling in a managed care organization to facilitate placement. However, the care plan was not updated to reflect the resident's current discharge goal, despite both the social worker and the director of nursing agreeing that the care plan should have been revised as soon as staff became aware of the change in the resident's goals.