Failure to Document Resident-Initiated Discharge and Placement Coordination
Penalty
Summary
The deficiency involves the facility’s failure to follow its discharge planning policy and to document the discharge process for one resident. The resident was admitted with metabolic encephalopathy and Alzheimer’s disease and was assessed as a short-term stay with capacity to understand and make decisions. An interdisciplinary care conference documented that the resident attended and that the discharge plan was to a room and board setting. A progress note later documented that the resident was discharged to a specified room and board with home health RN evaluation and treatment to follow. However, further review of the medical record showed no documented evidence of the events leading to the discharge. The Social Service Assistant (SSA) reported that she assists residents with placement to a lower level of care, coordinates home health and DME, and that the facility uses placement agencies whose representatives come to the facility. She stated that this resident was adamant about going home, asked daily about leaving, and that she referred the resident to a placement agency representative who discussed options, found a room and board, and that the resident agreed to that placement. The SSA acknowledged she did not document the resident’s repeated requests to leave or her referral and coordination with the placement agency representative, and stated she should have documented the discharge process and related communications. The DON stated he did not know if the SSA documented the resident’s request and referral, and believed that resident agreement and a care plan would be sufficient. The facility’s discharge planning policy required documentation of referrals to local contact agencies or other entities, updating the care plan and discharge plan based on referral information, and complete, timely documentation of the discharge needs evaluation and discharge plan in the clinical record, which was not done in this case.
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