Failure to Conduct and Document Effective Discharge Planning and Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process and to ensure care plans reflected specific discharge interventions for three residents. For one resident admitted in early February, the care plan documented a goal to discharge to an assisted living facility, but there were no specific interventions listed to help achieve this goal. The resident’s POA reported that no meetings had been held with her to discuss what interventions were being implemented to support the planned discharge. The medical record contained no documentation of discharge planning meetings with the IDT, the resident, or the resident’s representative. A second resident was admitted and later discharged home with home health services identified as the discharge plan. However, the care plan did not include specific interventions to assist the resident in meeting this discharge goal. There was no indication in the cited documentation that the comprehensive care plan or discharge plan had been updated with treatment preferences and needs related to the discharge. A third resident was admitted and later discharged home after Medicare Part A coverage ended. The resident’s family member reported being informed by a social services clerk that Medicare coverage would end on a specific date and that continued stay would cost a daily rate, and another staff member told her the resident had to leave by noon on the last covered day to avoid charges. The family member stated there had been no meetings with her or the resident to discuss the discharge or interventions needed for a safe discharge, and that the resident was discharged without medications, DME, home health information, community provider information, or follow-up appointment information. The care plan listed a goal to discharge home with home health services but lacked specific interventions, and the medical record did not contain documentation of discharge planning, attempts to obtain home health or DME, or a post-discharge plan of care. The administrator confirmed the absence of documented discharge planning meetings and care plan updates for all three residents and was unable to determine whether discharge plans had been discussed with the third resident or his family member.
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