Failure to Develop and Document Effective Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was reviewed for discharge. Specifically, the facility did not identify the resident's discharge needs or develop a discharge plan tailored to those needs. There was no evidence that the interdisciplinary team was involved in an ongoing process to create or update the discharge plan, nor was there documentation that the resident had been asked about their interest in returning to the community. Additionally, the resident's medical record lacked a comprehensive discharge summary, including a post-discharge plan of care, arrangements for follow-up care, and documentation of where the resident planned to reside after discharge. The resident in question had a history of alcohol abuse and had resided at the facility for several years. He was cognitively intact, as indicated by a BIMS score of 15, and expressed interest in going to rehab, with the expectation of returning to the facility after treatment. However, staff interviews revealed conflicting understandings of the resident's discharge intentions, with some staff expecting the rehab center to assist with permanent placement after the treatment program. There was no documentation in the clinical record reflecting the resident's intent to discharge, involvement in discharge planning, or a completed discharge summary. Interviews with facility staff, including the administrator, social worker, nurse practitioner, and director of nursing, confirmed the absence of required documentation and processes. The staff acknowledged that the resident's intent to discharge, assessment of self-care capability, discharge order, and summary were not present in the medical record. The facility's own policy required these elements, but they were not followed in this case, resulting in a deficiency related to discharge planning and documentation.