Failure to Develop Discharge Care Plan for Resident Returning Home
Penalty
Summary
The deficiency involves the facility’s failure to develop a care plan addressing a resident’s discharge plans. During an unannounced visit, surveyors reviewed the record of a cognitively intact resident admitted for aftercare following a below-knee amputation. The resident’s MDS showed a BIMS score of 15, and progress notes documented discharge plans to home with home health services. A physician’s order specified the last covered date and a planned discharge home on a specific date. Despite these documented discharge plans and orders, the resident’s care plan did not contain any problem, goal, or intervention related to discharge planning or the resident’s return home. Interviews with staff confirmed that a discharge care plan should have been in place. The Social Services Assistant stated that the Social Services Director is responsible for developing a care plan related to discharge plans and acknowledged that a discharge care plan is important to plan where the resident will go and what care and resources are needed before and at discharge. The Administrator stated that discharge care planning should be initiated upon admission, including discharge plans and care needs. The DON confirmed there was no discharge-related care plan for this resident and stated that social services should have initiated one on admission to ensure proper care to reach the discharge goal. A review of the facility’s transfer/discharge policy showed that details of transfers or discharges are to be documented in the medical record and communicated to receiving providers, but there was no corresponding discharge care plan for this resident.
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