Failure to Develop Discharge Care Plan and Involve Resident Representative
Penalty
Summary
The facility failed to develop and implement a discharge care plan for one resident who was reviewed for discharge planning. The resident, who had multiple diagnoses including a fractured sacrum, chronic bronchitis, COPD, repeated falls, altered mental status, depression, anxiety, and liver cancer, was admitted and later discharged home with family. Although the resident was cognitively intact and participated in therapies and goal setting for discharge, there was no evidence that a discharge care plan was created or included in the comprehensive care plan. Additionally, the discharge assessment did not indicate involvement of the resident or the resident's responsible party in the discharge planning process. The facility also did not ensure that the resident's responsible party, who was identified as the resident's representative in the admission agreement, was invited to participate in care planning meetings. Interviews with the DON and Administrator confirmed that neither the resident's family nor responsible party were provided invitations or notifications for care plan meetings, despite facility policy requiring their involvement. Documentation showed that the resident was notified of Medicare non-coverage and signed the appropriate form, but this did not substitute for the required discharge planning and involvement of the resident's representative.