F0627

D

Failure to Complete Required Discharge Planning and Documentation

Santa Monica, California Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to provide an effective and safe discharge for one resident by not following its own transfer and discharge policies and procedures. The resident had diagnoses including UTI, dysphagia, and adult failure to thrive, and an MDS assessment showed severely impaired cognitive skills and a need for moderate to maximal assistance with ADLs. Despite these needs, there was no care plan initiated regarding the resident’s discharge, including goals and interventions. The resident’s admission record showed a discharge date, and progress notes documented that the resident was discharged to a board and care facility, but the required discharge planning elements were not completed.

Review of the discharge summary/post-discharge plan of care revealed that it was undated and missing multiple required components, including the discharge plan, effective date, discharge date, discharge destination, physician follow-up appointments, post-discharge plans and community referrals, equipment needs, medication reconciliation, and nursing details such as functional status, vital signs, activity, nutrition status, and skin assessment. The DON confirmed that the IDT meeting form held prior to discharge lacked information on the discharge location, discharge date, post-discharge plans, equipment needs, physician follow-up visits, and functional status, and acknowledged that the discharge plan was incomplete with no information ensuring continuity of care. These omissions did not comply with the facility’s written policies on facility-initiated transfers/discharges and discharging the resident, which require comprehensive documentation, resident/representative notification and orientation, and a post-discharge plan reviewed at least 24 hours before discharge.