Failure to Develop and Implement Timely Discharge Plan
Penalty
Summary
A deficiency was identified regarding the facility's failure to develop and implement a timely discharge plan for a resident with diagnoses including diabetes mellitus, anxiety, depression, and difficulty walking. The resident was cognitively intact and independent with personal care, transfers, and ambulation. Although the Minimum Data Set (MDS) indicated an active discharge plan and a referral to the local contact agency, the resident's care plan did not include a discharge plan, and there was no documentation of referrals for potential discharge to another level of care. The interdisciplinary care plan meeting marked discharge planning as not applicable, with only a handwritten note referencing Money Follows the Person (MFP). Interviews revealed that a referral to MFP was made approximately 20 months prior, but the resident remained in the facility without further discharge planning or follow-up contacts regarding MFP or alternative settings. When the resident later requested a transfer to another nursing home, a referral was made and the resident was placed on a waiting list, but no additional follow-up was documented. The facility's discharge planning policy requires that discharge planning be addressed upon admission and throughout the resident's stay, particularly for those expressing a desire to return to the community, which was not consistently followed in this case.