Failure to Complete and Document Effective Discharge Planning and Instructions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and document an effective discharge plan of care for one resident, resulting in delayed initiation of home health care services and potential delay of follow-up appointments. The resident was admitted with multiple diagnoses, including a surgically repaired left femur fracture after a fall at home, anxiety, and left eye blindness, and was discharged home. Although a social work note early in the stay documented that the resident’s discharge plan was to return home, there was no comprehensive discharge care plan or discharge summary in the electronic health record, and progress notes over more than a month did not show evidence of discharge planning. Subsequent social work documentation indicated that the resident received a Notice of Medicare Non-Coverage and that the plan was for discharge home with home health care, and that the resident was discharged home without DME because it was reportedly already available at home. However, the required discharge planning elements outlined in the facility’s own Transfer and Discharge Guideline—such as evaluation of discharge goals, preferences, care needs, and development of a person-centered discharge care plan by the interdisciplinary team—were not reflected in the record. The resident’s needs and discharge plan were not documented as required, and there was no documented discharge summary including post-discharge services, follow-up details, or medication reconciliation. The resident’s “My Transition Home-Discharge” form was significantly incomplete, lacking the home health care agency’s phone number, information on follow-up appointments, and entries in sections for contact information, medication information, nursing instructions, dietary information, and discharge instructions. The resident later reported that it took a week after returning home to reach anyone from home care, and that the paperwork provided at discharge did not include any phone numbers, leading them to call the facility social worker multiple times to obtain the correct contact information. The Director of Social Services and the DON both acknowledged that the transition form was incomplete and that there was no discharge care plan or discharge summary documented for this resident.
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