Failure to Develop and Document Resident-Centered Discharge Goals and Rationale
Penalty
Summary
The deficiency involves the facility’s failure to develop and document discharge goals and to provide a documented rationale for determining that discharge was not feasible for a resident who wished to return home. The resident was admitted with chronic kidney disease and, per the MDS, had decision-making capacity and required varying levels of assistance with ADLs, including maximal assistance for toileting, showering, and lower body dressing, and partial assistance for transfers. Progress notes documented that an IDT meeting was held to discuss the resident’s desire to discharge home, and the IDT concluded the resident would remain in the facility until deemed safe for discharge by the MD. However, despite the resident expressing a desire to go home since a prior date, there was no documentation of specific discharge goals or a clear explanation in the record as to why discharge home was not feasible. The resident’s care plan contained general statements about evaluating and discussing prognosis for independent or assisted living, identifying limitations and needs for maximum independence, establishing a pre-discharge plan, arranging community resources, and monitoring for anxiety, fear, and distress. However, the record lacked evidence that these care plan elements were implemented in a resident-specific, measurable way. There was no documented assessment of the resident’s discharge needs, no documented exploration of community supports or alternative discharge options, and no measurable discharge planning interventions or objectives. The record also did not reflect ongoing communication with the resident about next steps in the discharge process. Interviews further supported the lack of documented discharge planning. The resident reported feeling emotionally distressed, uninformed about the discharge process, and believed the facility was not allowing discharge, stating he felt captured and had not seen a doctor since arrival. The SS, who was part of the IDT, stated the resident was not deemed safe to discharge and had decision-making capacity, but could not provide documentation outlining the specific clinical, functional, or safety factors that made discharge not feasible and acknowledged not updating the resident on discharge goals after the IDT meeting. The DON confirmed that the resident remained in the facility without documented discharge goals or a documented rationale for why discharge home was not feasible, despite facility policies requiring weekly IDT reevaluation of discharge potential, documentation of changes in the medical record, updating the care plan with the discharge plan, and documenting when returning to the community is not feasible and why.
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