Failure to Initiate and Document Discharge Planning for Resident Desiring Community Discharge
Penalty
Summary
Facility staff failed to initiate and document discharge planning for a resident who had an expressed goal and desire to return to the community. The resident was admitted with multiple medical diagnoses, including urinary tract infection, epididymitis, hydronephrosis, muscle weakness, ureteral calculus, urinary retention, dysphagia (oral phase), gait abnormalities, obstructive and reflux uropathy, hypertension, hyperlipidemia, and adjustment disorder with mixed anxiety and depressed mood. An MDS dated with a specified assessment date showed a BIMS score of 12, indicating some cognitive impairment, and documented that the resident’s overall goal was discharge to the community. Despite this, review of the medical record showed no documented discharge plan outlining an anticipated discharge destination, needed post-discharge services, or coordination with community providers. During an interview, the resident clearly stated a desire to leave the facility and have his indwelling catheter removed. The Social Services Director reported that discharge plans are typically documented in progress notes and discussed during IDT meetings within 7–10 days of admission, and that discharge planning includes determining equipment needs, anticipated discharge date, and contacting community agencies. The Social Services Director also stated that an application had been submitted to the Department of Aging for assisted living placement and that communication with the resident about discharge planning had occurred, but acknowledged this was not documented. A social services progress note from an IDT meeting documented that the resident was alert, oriented, in a bad mood, and had no questions or concerns, but did not include any discharge plan, anticipated discharge location, or post-discharge services. The DON stated that discharge planning begins at admission and should be documented in the EMR under social services progress notes, yet the record contained no documented discharge plan or communication with the resident regarding discharge planning, despite the resident’s stated goal and desire to discharge to the community.
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