Failure to Complete and Document Discharge Planning for Cognitively Intact Resident
Penalty
Summary
The facility failed to complete and document discharge planning for one cognitively intact resident. Facility policy required that discharge planning begin upon or shortly after admission, be incorporated into the baseline and comprehensive care plans, address the resident’s discharge goals and treatment preferences, identify the discharge destination, and ensure it met the resident’s health and safety needs and preferences. Record review showed that this resident, who had generalized muscle weakness, difficulty walking, a cognitive communication deficit, type 2 diabetes, morbid obesity, hypertension, and congestive heart failure, had no discharge plan initiated on the care plan. The resident’s Discharge MDS showed a BIMS score of 15, indicating intact cognition, and staff interviews confirmed the resident was able to make needs known. Documentation revealed the resident independently completed a rental application for an independent living apartment and later had a care plan conference record indicating no discharge plans and that the resident did not attend the conference. An email from the MDS LPN to the SSD, Administrator, DON, and Business Office Manager confirmed that the MDS LPN had received confirmation the resident was approved for independent living with a caregiver and was working with the Office on Aging to set up caregiver services. A progress note by the SSD on the discharge date stated the resident discharged to an independent living facility and refused assistance from SSD, and SSD was unable to confirm the transition. In interview, SSD stated there was no established discharge plan, that the resident had arranged the discharge and A&D waiver services independently, that SSD did not learn of the discharge plans until the day of discharge, and that the part‑time social services assistant had been collaborating with the resident. SSD was unable to provide any documentation of a discharge plan and confirmed they could not prove that discharge planning documentation had been completed.
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