Failure to Develop and Initiate Discharge Plan for Medically Complex Resident
Penalty
Summary
The facility failed to ensure that the discharge needs of a resident were identified and that the discharge planning process resulted in the development of a discharge plan when a 30-day discharge notice was issued due to non-payment. The resident in question had a complex medical history, including coronary artery disease, diabetes mellitus, heart failure, COPD, peripheral vascular disease, hypertension, prior stroke, chronic kidney disease, anoxic encephalopathy, and was ventilator dependent with a tracheostomy and PEG tube. The resident was bedbound, in a persistent vegetative state, and required extensive care for multiple stage IV pressure ulcers. Despite these significant care needs, the facility did not initiate a discharge plan at the time the discharge notice was issued. Record review showed that the resident's care plan did not include a discharge plan, and the quarterly MDS assessment left the resident's overall goal blank, with no active discharge planning or referral to the Local Contact Agency. The responsible party for the resident had not paid the required applied income, leading to the issuance of the discharge notice. Facility staff, including the DON, ADONs, and Business Office Manager, reported that the social worker responsible for discharge planning had left the facility, and a replacement was not in place during the critical period. Attempts to contact the responsible party were limited to phone calls and emails, with no other methods used to facilitate discharge planning or ensure the resident's needs and preferences were addressed. Interviews with facility staff confirmed that no discharge plan was developed or initiated when the discharge notice was issued. The scheduled orientation for discharge planning was not conducted, and there was no documentation of efforts to coordinate a safe and appropriate discharge for the resident, who remained in a highly dependent state. The facility's own policy required assessment of continuing care needs and coordination of post-discharge services, but these steps were not taken in this case.