Failure to Initiate and Document Discharge Planning for Resident Requesting Discharge
Penalty
Summary
The facility failed to initiate and document a discharge plan for a resident who requested to be discharged. According to facility policy, residents may not be discharged unless specific criteria are met, and the facility must provide written notice, physician documentation, and coordinate discharge planning with social services, nursing, MDS, and therapy. The policy also requires that the discharge notice include the reason for discharge, effective date, appeal rights, and discharge location, as well as the development of a post-discharge plan of care. In this case, the resident, who was cognitively intact and admitted for short-term rehabilitation due to cellulitis of the lower limb, expressed a desire to leave the facility and live with family. The resident had communicated this wish to the social worker for several weeks, but no discharge plan was documented or initiated. Review of the clinical record showed that while the social worker was aware of the resident's wishes and had attempted to contact the resident's daughter, there was no evidence of a coordinated discharge plan or documentation of the required notifications. The care plan did not mention discharge planning, and the nursing home administrator confirmed that no steps had been taken to facilitate the resident's discharge. Physical therapy notes indicated the resident was expected to return home with family support and identified potential barriers, but these were not addressed in a formal discharge plan. The deficiency was identified through review of facility policy, clinical records, and staff and resident interviews.