Failure to Develop and Document Post-Discharge Plan for Resident Transferred to Board and Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its policy and procedure titled "Transfer or Discharge, Preparing a Resident for" for one of three sampled residents. The resident was admitted with diagnoses including HTN, HLD, epilepsy, and difficulty in walking, and the History and Physical documented that the resident had the capacity to understand and make their own medical decisions. The Order Summary Report showed a discharge-related order entered for a follow-up appointment with a doctor and a later order authorizing discharge to a board and care with home health services for PT, OT, RN safety visits, and DME in the form of a wheelchair. During an interview with concurrent record review, the DON confirmed that there was no post-discharge plan documented in the resident’s record, despite the facility’s policy requiring that a post-discharge plan be developed for each resident prior to transfer or discharge and assigning nursing services responsibility for preparing that plan. The DON acknowledged that, based on the documentation, there was no way to know if home health services were arranged or if the follow-up doctor’s appointment was communicated to the board and care. This lack of documented post-discharge planning and coordination constituted the cited failure to ensure the transfer/discharge met the resident’s needs and preferences and that the resident was prepared for a safe transfer/discharge.
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