Failure to Develop and Implement Resident-Centered Discharge Planning
Penalty
Summary
The facility failed to develop and implement discharge planning processes that focused on a resident's discharge goals, as required by facility policy and regulatory standards. Specifically, for one resident with diagnoses including cerebral infarction, Moyamoya disease, and diabetes mellitus, who was assessed as cognitively intact and expressed a goal to return to the community, the facility did not document a comprehensive discharge plan or goals of care related to returning home. Although the resident and physician discussed plans for discharge to home with a paid caregiver, these plans were not reflected in the resident's care plan or supported by appropriate documentation in the clinical record. The facility's policies require that a post-discharge plan be developed and reviewed with the resident or their representative at least 24 hours before discharge, and that nursing services obtain discharge orders, prepare summaries, and provide necessary documentation to the resident or caregiver. However, the clinical record for the resident did not contain evidence of a physician's order for discharge, a documented discharge summary, or a post-discharge plan of care. Additionally, there was no documentation that the required information was communicated to the receiving provider or that the resident or caregiver received the necessary discharge documents. During an interview, the DON confirmed that the facility did not develop or implement discharge planning processes that addressed the resident's discharge goals. The lack of documentation and planning was identified through a review of facility policy, clinical records, and staff interviews, and was found to be out of compliance with several state regulatory requirements regarding resident care policies, management, and resident rights.