Resident Not Included in Discharge Planning Process
Penalty
Summary
The facility failed to ensure that a resident was included in the discharge planning process, as required by policy. Review of the resident's medical record revealed that, although the resident had a complex medical history including end stage renal disease on hemodialysis, peripheral artery disease, and multiple amputations, there was no documentation of any conversation with the resident regarding discharge planning until several days after admission. The first documented interaction between the discharge planner and the resident occurred only after four prior care management progress notes had been completed, none of which indicated the resident's involvement in the discharge planning process. During an interview, the Director of Case Management and Social Services confirmed that it is important for discharge planners to meet with residents within one to two days of admission to ensure their preferences are incorporated into the discharge plan. The facility's policy also requires care management staff to engage the patient or their representative in the discharge planning process and to consider their preferences. The lack of early engagement with the resident meant that the resident's needs and preferences may not have been fully considered during the initial stages of discharge planning.