F0627

D

Failure to Align Discharge Planning With Resident Goals and Provide Complete Discharge Instructions

Ebensburg, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to develop and implement a discharge planning process that aligned with a resident's stated goal of remaining for LTC and failed to provide complete discharge instructions, including medication times and dosages. The resident was admitted after a fall at home resulting in a traumatic brain bleed and was assessed as cognitively intact but needing assistance with daily care. A comprehensive MDS and care plan documented that his goal was LTC placement. Social services notes, a CRNP note, and an interdisciplinary team meeting all recorded that the resident did not want to return to his prior living arrangement due to inability to manage stairs, living alone, and being unable to care for himself, and that he was willing to apply for state insurance to stay for LTC.

Subsequently, social services documented that the resident was issued a NOMNC and would discharge home, but there was no evidence in the clinical record that the facility followed up with the resident or family regarding this change in plan to ensure his safety upon discharge. Therapy assessments and goals remained focused on LTC, and the Rehab Program Manager confirmed that therapy was not notified of the change in goal until shortly before discharge and had not worked with the resident on home-related tasks such as housework, cooking, laundry, or stair training, despite knowing he had 12 stairs at home. The case manager did not inform the insurer that the resident’s goal had changed from LTC to going home, and the Nursing Home Administrator acknowledged that the resident was discharged without written instructions listing his medications, including times, dosages, and which medications to discontinue.