Incomplete Discharge Planning and Documentation
Penalty
Summary
The facility failed to complete discharge planning for a resident with a history of hemiplegia, hemiparesis following cerebral infarction, and orthostatic hypotension, who was homeless prior to admission. The resident's discharge care plan included goals for appropriate placement and safe transition to the community, with interventions to assess preferences and coordinate necessary services. However, documentation revealed that there was no finalized discharge date or documented place of discharge. Social service notes indicated ongoing discussions about discharge, but no specific date was set, and the discharge ultimately occurred on a day not planned by the interdisciplinary team (IDT). The Social Service Director (SSD) and Director of Nursing (DON) both confirmed that the discharge was unplanned and not communicated or documented as required. On the day of discharge, the resident left the facility with his son, and the SSD was not present to document the destination or ensure the discharge plan was finalized. The facility's policy required a finalized discharge plan, including the resident's destination, to be reviewed with the resident and family at least 24 hours prior to discharge. This process was not followed, and the discharge summary lacked essential information about the resident's post-discharge arrangements. The lack of documentation and communication resulted in incomplete discharge planning for the resident.