Failure to Develop and Implement Timely Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing discharge needs for three out of five residents reviewed for discharge care planning. According to the facility's policy, a comprehensive care plan, including discharge planning, should be developed within seven days of completing the comprehensive MDS assessment. However, for one resident, the discharge care plan was initiated only on the day of discharge, and for two other residents, no discharge care plan was documented prior to or at the time of discharge. Review of the electronic health records confirmed the absence or late completion of these required care plans. Interviews with facility staff revealed that the interdisciplinary team was responsible for care plans based on medical needs, while the Social Services Department handled discharge care plans. The Social Services Director stated that discharge care plans were to be completed within 72 hours of admission, but acknowledged that for the residents in question, this was not done in a timely manner or at all. The Director of Nursing Services confirmed that discharge care plans should have been completed within seven days after the admission MDS assessment, but this requirement was not met for the affected residents.