Failure to Implement and Document Ongoing Discharge Planning for Short‑Stay Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document an ongoing discharge plan for a short‑stay resident to ensure a safe and effective transition back into the community. The resident had diagnoses including bacteremia, intraspinal abscess and granuloma, and anxiety disorder, and was admitted for short‑term rehabilitation after a hospital stay. On admission, the social service note documented that the resident had unstable housing, had been living at a friend’s house prior to hospitalization, and that discharge plans were discussed with the resident stating they would return to the friend’s house if no other housing options were available. The note also indicated a referral would be made to Money Follows the Person for housing supports, and the admission MDS and care plan identified a goal of discharge back into the community with social services and the IDT to coordinate needed equipment, services, and community resources. A Level of Care Screen by Maximus later confirmed that short‑term care was appropriate for a defined period and directed the facility to continue assisting with discharge planning for appropriate community and support services. Psychological services documented that the resident was experiencing anxiety related to potential early discharge and that the plan was to continue addressing discharge‑related anxiety. An APRN progress note indicated the resident had completed IV antibiotics, was clinically stable, and was preparing for discharge home later that week, pending final coordination. A Transition of Care/Discharge Summary identified an anticipated discharge date and a planned discharge location back into the community. Despite these documented goals and clinical readiness for discharge, review of social service notes from admission through the anticipated discharge date did not show evidence that social services had been working with the resident on discharge back into the community. There was no documentation of IDT collaboration, referrals and resources provided for post‑discharge needs, discharge readiness, or the resident’s participation in the discharge planning process, as required by facility policy. The social worker reported that discharge planning discussions occurred and that she met with the resident to discuss anticipated discharge, encouraged the resident to contact family and friends, and provided 211 as a resource, but these actions were not documented in the clinical record. The resident reported being told they were ready for discharge, needing to secure housing, being told to call 211 if housing could not be found, and feeling there was no ongoing assistance from the facility to secure housing or discussion of aftercare. Facility policy required that discharge planning begin at admission, be reviewed weekly for short‑stay residents, and that progress notes include participants, readiness for discharge, services arranged, and teaching provided, which was not reflected in the record for this resident.
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