Failure to Develop Discharge Care Plans for Three Cognitively Intact Residents
Penalty
Summary
The facility failed to develop discharge care plans for three sampled residents, despite facility policy that discharge planning begins at admission and should be updated after discharge meetings and every three months. Interview and record review showed that Residents 1, 2, and 3, all with intact cognition, did not have discharge care plans in their medical records. The medical record assistant confirmed that no discharge care plans were found for these residents, and the director of social services stated that discharge planning is expected to start at admission. Resident 1, an older female admitted with a left humerus fracture, generalized muscle weakness, encephalopathy, cystitis, bilateral knee osteoarthritis, anxiety, hypertension, major depressive disorder, and repeated falls, was documented as dependent for toileting, bathing, and transfers. Resident 2, an older female with osteoarthritis of the knee, morbid obesity, dysphagia, schizoaffective disorder, bipolar disorder, and glaucoma, was also dependent for toileting, bathing, and transfers. Resident 3, an older female with spinal stenosis, fibromyalgia, knee osteoarthritis, diabetes mellitus, morbid obesity, anxiety, insomnia, GERD, and major depressive disorder, required maximal assistance with toileting, bathing, and transfers. Despite these documented care needs and intact cognition, no discharge care plans were developed for any of the three residents.
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