Failure to Develop and Implement Resident-Specific Discharge Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, resident-specific care plans were developed and implemented for two residents regarding discharge planning. For one resident with diagnoses including hypertension, congestive heart failure, chronic pain disorder, and major depressive disorder, the care plan included only a general intervention for social services to assist with discharge planning. The care plan did not specify the resident's preferences or potential for future discharge, nor did it document whether the resident's desire to return to the community was determined, despite the resident being cognitively intact. For another cognitively intact resident with diagnoses such as pneumonia, kidney transplant status, end stage renal disease, and anemia, there was no specific care plan initiated to address discharge planning. Staff interviews confirmed that care plans are updated at least quarterly or with significant changes, and that the two residents in question did not have completed, resident-specific discharge care plans. Policy review indicated that care plans should include measurable objectives, timeframes, and reflect the resident's goals and preferences, which was not followed in these cases.