Failure to Develop and Implement Discharge Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive discharge care plan interventions for four of five residents reviewed for discharge planning. Facility policy on discharge care planning requires that, when a resident is discharged, a post-discharge plan be provided to the resident and/or representative, including the resident and family’s preferences for care, how services will be accessed and paid for, coordination of care among multiple caregivers, identification of specific needs at discharge (such as ADLs, self-administration of medications, diet, sterile dressings, and therapy), appropriate referrals by social services, and preparation for discharge. The comprehensive care plan policy also requires an individualized plan with measurable objectives and timetables to meet each resident’s medical, nursing, mental, and psychological needs. Despite these policies, the electronic medical records for four residents admitted for care did not contain discharge plans or related interventions. One resident reported that discharge plans were not discussed until an involuntary discharge notice was given, and his current care plan lacked any discharge planning or interventions. Another resident’s record similarly showed no documented discharge plan or interventions. A third resident, who stated he would be going home after completing therapy, reported that no one had discussed discharge plans with him, that his family was independently looking into home health services, and that discharge was never addressed during his care plan meeting; his care plan also lacked discharge planning or interventions. A fourth resident was admitted and later discharged home without any documented discharge plan or interventions in the care plan. The Minimum Data Set Director/RN stated that discharge planning is supposed to be initiated upon admission and that the Social Service Director is responsible for documenting the discharge portion of the care plan. The Social Service Director acknowledged being responsible for discharge care planning, stated she had fallen behind, and confirmed that these four residents did not have discharge plans on their care plans.
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