Failure to Document and Implement Discharge Planning in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement a discharge planning process and include this process in the electronic medical record and comprehensive care plan for two of three residents reviewed for discharge planning. One resident expressed uncertainty about his discharge date and reported not being informed about his discharge plans, aside from being told he would be discharged. Staff interviews revealed that discharge planning was not documented in the electronic medical record or care plan, and communication about discharges was primarily through dashboard alerts. The care plan for this resident did not include any discharge planning, and there were no physician orders for discharge at the time of review. The facility's policy requires that the comprehensive, person-centered care plan contain the resident's goals for admission and desired outcomes aligned with discharge, with supporting documentation of the resident's intent to leave and documented discussions, which was not present in this case. Another resident also did not have a discharge plan documented in her care plan, despite her goal to return to the community being noted in the Minimum Data Set. She was unaware of her discharge plan and only knew she would be receiving cancer treatment. The care plan lacked any information related to discharge, and staff confirmed that a discharge plan should have been in place. Both residents had complex medical histories, including chronic conditions and recent treatments, but the required discharge planning and documentation were not completed as per facility policy.