Failure to Develop Discharge Care Plan for Resident with Severe Cognitive Deficits
Penalty
Summary
The facility failed to develop a discharge care plan for one of three sampled residents following re-admission. The resident in question had a history of cerebrovascular disease and was assessed with severe cognitive deficits, as indicated by a BIMS score of 2 out of 15. Despite the resident's complex needs, there was no evidence of a current or revised discharge care plan after re-admission. The Social Service Designee (SSD) initially planned for the resident to be discharged to a sister facility in another state, but later learned from the resident's family member that the preferred discharge location was closer to the family in California. However, the SSD was unable to locate any updated discharge care plan reflecting this change or the resident's needs. Interviews with facility staff, including the SSD and the Director of Nursing (DON), confirmed that discharge planning and care plans were not initiated or updated in a timely manner. The DON acknowledged that discharge care plans should be developed and revised based on the resident's condition, care needs, and input from the interdisciplinary team (IDT), as well as discussed with the resident or their representative. A review of facility policy also indicated that comprehensive, person-centered care plans are required to be developed by the IDT. The absence of a discharge care plan following the resident's re-admission constituted a deficiency in meeting regulatory requirements for care planning.