Failure to Update and Revise Person-Centered Discharge Care Plan
Penalty
Summary
The facility failed to update and revise a person-centered discharge care plan for one of three sampled residents. The resident, who had a history of Diabetes Mellitus and no cognitive deficits as indicated by a perfect BIMS score, was re-admitted to the facility and had a discharge care plan initiated at the time of re-admission. However, the discharge care plan was not revised or updated as the resident's condition and planning needs changed. There was no documentation of revised discharge goals or updated interventions for a safe transition since the baseline care plan was initiated, and no interdisciplinary team (IDT) review was completed during the scheduled care conference. Interviews and record reviews revealed that the Social Service Designee (SSD) acknowledged the discharge care plan was not person-centered and had not been updated within the required timeframe or as the resident's needs changed. The SSD also confirmed that the care plan was not reviewed by the IDT and was not discussed with the resident or their representative. The Director of Nursing (DON) further stated that discharge care plans must be continuously updated and coordinated with the IDT, and acknowledged that this had not occurred for the resident in question.