Failure to Include Discharge Plan in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that included a discharge plan for one resident. The resident in question was admitted with multiple complex diagnoses, including sepsis, stage 4 pressure ulcer, chronic kidney disease, muscle wasting, and bilateral lower extremity DVTs. Upon review, the resident's care plan did not contain any documentation of a discharge plan, despite facility policy requiring such plans to be developed within 7 days of the comprehensive assessment. Interviews with facility staff, including the Rehabilitation Director, MDS Coordinator, DON, and Social Services Director, confirmed that the resident was considered a short-term admission and that a decision regarding her inability to return home was made recently. However, no discharge plan was documented in her care plan. Observations of the resident showed she required significant assistance with activities of daily living and 24-hour care. Staff interviews revealed that the resident had memory concerns and lacked capacity to make informed decisions, as documented by the physician. Despite these needs and the facility's own policy, the care plan did not address discharge planning, and staff confirmed the omission upon review of the electronic clinical record. The facility's policy specifically requires that the care plan include the resident's goals for admission, desired outcomes, preferences for future discharge, and discharge plans as appropriate, which was not followed in this case.