Failure to Provide Competent, Person-Centered Discharge Planning and Education
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff had and applied appropriate competencies in discharge planning and resident/family communication for one resident. The resident was admitted with multiple medical conditions, including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A History and Physical documented that the resident had the capacity to understand and make decisions, while an MDS assessment showed moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and dressing below the waist. A physician’s order directed that the resident be discharged home with home health services. The facility did not develop an individualized, person-centered care plan addressing the resident’s discharge needs, including the involvement of the responsible party. The Assistant Director of Nursing (ADON) acknowledged that the discharge care plan only reflected the resident’s wish to return home and did not discuss education or involvement of the family to prepare them for discharge. The ADON also noted that the care plan for the resident’s Foley catheter, which had been reinserted during the stay, included monitoring for signs and symptoms of UTI but did not address catheter care or resident/family teaching on interventions. There was no documentation that the discharge planning process considered caregiver/support person availability or capacity to perform required care, nor documentation of return demonstration or understanding by the resident or family. At the time of discharge, the facility failed to provide discharge instructions and teaching to the resident or responsible party. The responsible party reported repeatedly telling staff that the resident was not ready for discharge and described the discharge as unorganized and unsafe, stating that no discharge instructions were given and that no information was provided on how to appeal the discharge. The resident was discharged home with an IV access still intact, which was later confirmed by an LVN who recalled discharging the resident with an IV and recognized that an IV access site could lead to infection or bleeding requiring emergency care. The ADON and DON both acknowledged that the discharge order and transfer/discharge report did not include information about the IV or Foley catheter, and that the facility failed in communication and education of the resident and family regarding the resident’s needs, demonstrating a lack of nursing staff competency in person-centered care and communication as required by facility policy. The facility’s written policies required development of a comprehensive, person-centered care plan by the interdisciplinary team, with measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs, and required advance notice and involvement of the resident and representative in care planning conferences. The discharge planning policy required identification of discharge needs on admission, timely development and implementation of a discharge plan, regular reevaluation and updating of the plan, consideration of caregiver availability and capability, involvement of the resident and representative in the discharge plan, and documentation of preparation and orientation to ensure a safe and orderly transfer or discharge. The nursing staff competency policy required sufficient nursing staff with appropriate competencies, including resident rights, person-centered care, and communication. The events surrounding this resident’s discharge, including the lack of individualized discharge care planning, lack of documented teaching and understanding, and discharge with an IV still in place, demonstrate that these policies were not implemented for this resident.
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