Failure to Ensure Safe and Timely Discharge Planning
Penalty
Summary
The facility failed to adequately assist residents with discharge planning, resulting in unmet discharge needs for two residents. For one resident admitted with blood clots in the lungs and chronic obstructive pulmonary disease, the care plan indicated a short-term stay and required coordination with the physician and community referrals. However, the resident’s power of attorney (POA) repeatedly requested assistance in setting up a primary care provider (PCP) and home caregivers, but was told by staff that this was not the facility’s responsibility. Documentation showed ongoing communication issues, incomplete discharge planning assessments, and a lack of coordination among staff, leading to delays and the resident threatening to leave against medical advice due to feeling unprepared for discharge. For another resident with congestive heart failure and cirrhosis, the care plan documented a long-term stay, but there was no evidence of a discharge evaluation, care conference notes, or progress notes regarding discharge goals. The social service evaluation was incomplete, with key sections left blank, including the resident’s wishes for discharge and anticipated length of stay. Although social services staff reported working on community housing for the resident, this was not documented in the medical record or reflected in the care plan. The resident ultimately left the facility against medical advice, and staff acknowledged the absence of a documented discharge plan or reassessment. Interviews with staff, including the Director of Nursing and social services, confirmed confusion and lack of communication regarding discharge planning for both residents. Staff admitted that necessary services, such as arranging a PCP and caregiver support, were not set up, and that discharge planning was not properly documented or coordinated. These failures resulted in delayed or unsafe discharges and were not aligned with the residents’ needs or preferences.