Failure to Provide Comprehensive, Person-Centered Discharge Planning and Education
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered discharge care plan for a resident, including measurable objectives and timeframes, and to involve the resident’s responsible party. The resident was originally admitted with multiple diagnoses, including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. The resident’s MDS showed moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order indicated the resident was to be discharged home with home health services, but the discharge care plan did not specify goals, interventions, or family involvement needed to prepare the resident and responsible party for discharge. The facility did not provide an individualized discharge care plan that addressed the resident’s specific needs, including management of a Foley catheter and IV access, nor did it document that the resident or responsible party received or understood discharge teaching. The ADON acknowledged that the discharge care plan only reflected a wish to return home and did not discuss education or involvement of the family to prepare them for discharge. The care plan for the Foley catheter included monitoring for signs and symptoms of UTI but did not address catheter care or teaching for the resident or family. The facility’s own policies required that the IDT develop a comprehensive person-centered care plan with measurable objectives and timeframes, and that the discharge planning process involve the resident and representative, consider caregiver capacity, and provide sufficient preparation and orientation for a safe and orderly discharge, but these elements were not documented or implemented for this resident. The resident was discharged home with an IV still intact, and there was no documentation in the discharge order or transfer/discharge report that the resident was being discharged with an IV or Foley catheter, nor any related instructions. An LVN who discharged the resident recalled that the resident left with an IV in place and recognized that an IV access site could lead to infection or bleeding. The resident’s responsible party reported repeatedly stating that the resident was not ready for discharge and described the discharge as unorganized and unsafe, noting that the resident went home with an IV port and that no discharge instructions were given to anyone. The DON and ADON both confirmed that the facility failed to conduct a comprehensive, person-centered discharge care plan specific to the resident’s needs and did not show family involvement or the types of education needed for discharge, and that there was no documentation of caregiver capacity, return demonstration, or understanding as required by facility policy.
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