Failure to Develop Individualized Discharge Plans Reflecting Resident Goals
Penalty
Summary
The facility failed to develop and implement individualized discharge planning that addressed residents' discharge goals and incorporated those goals into their comprehensive care plans for two residents. One resident with schizophrenia, who was cognitively intact with a BIMS score of 15, had an MDS Section Q assessment indicating that the overall discharge plan was unknown and that no active discharge planning process was occurring for a potential return to the community. The resident’s comprehensive care plan, initiated months earlier and recently reviewed, contained no interventions, goals, or planning related to discharge preferences, discharge planning activities, or barriers to discharge, despite documentation that the resident expressed a desire to return to the community and live with his sister. The DON reported that the sister did not want the resident to live with her and that the resident’s complex history made community discharge difficult, but these considerations and barriers were not documented in the care plan. Another resident with dementia and moderate cognitive impairment, reflected by a BIMS score of 12, also had an MDS Section Q assessment documenting that the overall discharge plan was unknown and that no active discharge planning process was occurring for a return to the community. This resident’s comprehensive care plan, initiated after readmission following an unsuccessful discharge, did not include discharge planning goals, interventions, or evaluation of discharge options, even though the record showed the resident continued to express a desire to return home. The Social Services Director stated that the resident occasionally expressed a desire to go home but that discharge was considered unsafe due to the resident’s inability to care for herself and the home being described as uninhabitable; however, no discharge care plan addressing the resident’s stated preference, barriers to discharge, or alternative options had been developed. The NHA and DON were unable to provide documentation showing individualized discharge care plans for either resident.
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