Failure to Provide and Document Discharge Planning Social Services
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services and discharge planning for two residents who expressed or required consideration for alternative placement. One resident with a history of seizures, schizoaffective bipolar disorder, PTSD, suicidal ideation, intentional self-harm, mood disorder, and epilepsy stated she wanted to be discharged to a setting similar to her prior residential group home. She reported that social services were trying to find a place for her but had not informed her of the status, and that social services staff told her no one would accept her if she was lying. The social services worker confirmed the resident had lost her apartment during the facility stay, that the prior group home refused readmission without giving a reason, and that developmental disability homes indicated they could accept the resident when she was able to walk, noting she had recently started walking. The psych NP and RN both stated the resident would benefit from a setting specializing in mental health services with peers her own age, and the RN noted staff were not trained to care for psychiatric residents. Despite a care plan stating that discharge planning should be continually assessed and that social services would assist in finding a group setting, social service notes from September through late January contained no documentation of discharge planning or contacts with group homes or facilities for placement. The second resident was admitted from an acute care hospital with cirrhosis, alcohol abuse, restless leg syndrome, insomnia, and major depressive disorder, and reported being independent with care and ambulation. He stated there had been discussion about finding alternative placement, while social services reported that the plan was for him to remain at the facility and that he became defensive when asked about discharge planning, confirming he was independent and not receiving therapy. The administrator described him as a young male resident who goes out on pass independently and stated he was at peace and complacent at the facility but had nowhere else to go. Social service documentation described him as alert, oriented, able to communicate needs, ambulating independently with a walker, a smoker, and having an independent community pass. However, social service notes from November through January contained no documentation of discharge planning, and the regional nurse consultant confirmed there was no documentation of discharge planning or attempts to find alternative placement for either resident, despite facility policy requiring social work involvement in assessing discharge potential, documenting significant discharge information, and coordinating community services.
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