Failure to Develop and Document Discharge Plan for Resident
Penalty
Summary
A deficiency was identified when the facility failed to develop a discharge plan for one of three residents reviewed for discharge planning. The facility's policy requires that each resident's comprehensive care plan be consistent with their rights to participate in the development and implementation of their care, including establishing goals and outcomes. The resident in question was admitted with diagnoses including paraplegia, anxiety disorder, PTSD, and recurrent depressive disorders, and was found to be cognitively intact and his own decision maker. Despite these factors, there was no documentation of a care conference or a discharge care plan in the resident's medical record. During interviews, the resident confirmed that no one had discussed discharge planning with him and that he had not participated in a care conference. The social worker explained that the usual process involves setting up a care conference within 5-7 days of admission and another meeting 1-2 weeks later to address equipment and support needs, with documentation under the assessments tab. However, upon review, both the surveyor and the social worker confirmed that there was no documentation of a care conference or discharge care plan for this resident, indicating a failure to follow the facility's established discharge planning process.