Failure to Notify Physician and Document Discharge Planning for Resident Requesting Return Home
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and to follow through on discharge planning as documented in an Interdisciplinary Team (IDT) meeting for one resident. The resident was admitted with chronic kidney disease and, per a recent MDS, had decision-making capacity and required varying levels of assistance with ADLs, including cleanup assistance for eating and oral hygiene, maximal assistance for toileting, showering, lower body dressing, and footwear, and partial or supervisory assistance for transfers and upper body care. The resident’s care plan, initiated months earlier, included interventions to evaluate and discuss prognosis for independent or assisted living, identify and address limitations and risks, establish and revise a pre-discharge plan, arrange community resources, and monitor for anxiety, fear, and distress. Record review showed that an IDT meeting was held to discuss the resident’s ongoing desire to discharge home, which the resident had been expressing since the prior year. The IDT documented that the resident would remain in the facility until full recovery and that discharge home would occur once deemed safe by the MD, and the IDT notes stated that the physician would be notified regarding the resident’s request and the team’s determination that discharge was not safe. However, as of the survey date, there was no documentation that the physician had been notified, no physician progress note addressing discharge appropriateness, no physician orders related to discharge planning or safety concerns, and no follow-up documentation indicating that any consultation occurred. Interviews confirmed these documentation gaps and failures in communication. The resident reported not having seen a doctor since arrival at the facility and described emotional distress, frustration, and feeling uninformed about discharge goals, discharge planning, and the steps needed to return home. The resident stated that a meeting about going home had occurred but that nothing further was done. The social services staff, who participated in the IDT, stated that the resident was not deemed safe to discharge but could not provide documentation of the specific clinical, functional, or safety factors supporting that conclusion, acknowledged that the resident had decision-making capacity, and admitted she had not updated the resident on discharge goals or notified the physician as indicated in the IDT summary. The DON stated that the resident remained without documented discharge goals or a documented rationale for why discharge home was not feasible and that someone from the team should have notified the MD to evaluate the resident for discharge goals, consistent with the facility’s policy requiring communication of marked physical or psychological changes to the physician for proper management.
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