Failure to Develop and Document Discharge Planning for Hospitalized Resident
Penalty
Summary
Facility staff failed to develop and document effective discharge planning for a resident who was hospitalized and subsequently discharged from the facility. The resident had multiple diagnoses including fluid overload, hypertension, a right heel skin ulcer with muscle necrosis, dementia, heart failure with reduced ejection fraction, and iron deficiency anemia. On 01/23/2026 at 07:24, nursing notes documented that the resident was in bed, awake but hypotensive, febrile, with altered mental status and lethargy, though without shortness of breath or distress, and the physician ordered transfer to the nearest ER via 911, with the resident’s responsible party notified. Later that day, a progress note listed hospitalization with the hospital identified as the resident’s discharge location. The care plan review on 03/10/2026 showed the resident’s care plan was closed on 02/10/2026 with the reason marked as “discharged.” However, there was no documented evidence in the medical record of discharge planning or additional information related to discharge planning after the resident’s hospitalization, and during a face-to-face interview the DON stated the patient was discharged, while acknowledging there was no documented discharge reason with location for the resident’s discharge. These findings reflect that the facility did not ensure the transfer/discharge process met the resident’s needs and preferences or that the resident was prepared for a safe transfer/discharge, as required, due to the absence of documented discharge planning despite the resident’s hospitalization and discharge status in the record.
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