Failure to Provide Person-Centered Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered discharge care plan for one resident. Resident F, whose diagnoses included traumatic brain injury, acute respiratory failure, cannabis dependence, and alcohol dependence, was reviewed on 3/4/26, and the clinical record showed a progress note dated 2/10/26 documenting that the resident was discharged with medications and belongings. However, the clinical record lacked any person-centered discharge care plan, and there was no evidence that such a plan had been created or provided to the resident at discharge. During an interview, an LPN confirmed that the resident should have had a person-centered discharge care plan in place and that a copy should have been given to the resident upon discharge. The Administrator provided the facility’s current “Transfer and Discharge” policy, dated 6/2020, which stated that residents will have a comprehensive person-centered discharge care plan. The absence of such a plan in Resident F’s record, despite the documented discharge and the facility’s policy requirement, formed the basis of the deficiency cited under 410 IAC 16.2-3.1-35(a) related to Intake 2743057.
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