Failure to Develop and Implement Discharge Planning in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing discharge planning for two residents. For one resident admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and atrial fibrillation, the Minimum Data Set (MDS) indicated substantial assistance was needed for activities of daily living. Despite the Social Services Director stating that discharge planning begins at admission and involves identifying the resident's discharge preferences and necessary resources, a review of the resident's care plan revealed no focus, goal, or intervention related to discharge planning. The Director of Nursing confirmed the absence of discharge planning in the care plan and acknowledged its importance for ensuring a safe and organized discharge process. Similarly, another resident admitted with seizures, hypertension, and depression, and assessed as requiring varying levels of assistance with daily activities, also lacked a care plan addressing discharge planning. The resident's MDS and medical history indicated the capacity to make decisions, yet the care plan did not include any discharge planning components. The Director of Nursing again confirmed that social services are responsible for this aspect of care planning and that its omission could lead to disorganized and stressful discharges. A review of the facility's policies and procedures confirmed that comprehensive, person-centered care plans with measurable objectives and timetables are required for each resident, and that social services staff are responsible for transitions of care, including discharge planning. The job description for the Social Services Director also specified responsibilities for discharge-planning services, such as referrals, follow-up arrangements, and post-discharge care plans. Despite these documented requirements, the facility did not ensure that discharge planning was included in the care plans for the two residents reviewed.