§483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
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Observations:
Based on a resident representative interview, a clinical records review, and staff interviews, it was determined that the facility failed to develop and implement a safe discharge plan for one of the 11 residents reviewed (Resident CR1).
Findings included:
A clinical record review revealed Resident CR1 was admitted to the facility on December 10, 2024, with diagnoses that included chronic kidney disease (gradual loss of kidney function) and traumatic brain injury (a brain injury caused by a sudden, external force to the head).
A review of a discharge Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 27, 2024, revealed that Resident CR1 is moderately cognitively impaired with a BIMS score of 08 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment).
A progress note dated December 17, 2024, at 11:14 AM indicated Resident CR1 requires 30 hours a week of caregiver support. The note indicated an external service provider is assisting with coordinating discharge care.
A physical therapy discharge summary dated December 26, 2024, revealed discharge recommendations for Resident CR1 to receive continued physical therapy services to maximize safe functional mobility. Additionally, the discharge summary indicated recommendations for Resident CR1 to have significant supervision and assistance greater than 12 hours a day due to impaired cognition and safety.
A clinical record review revealed no documented evidence indicating the total amount of supervision and assistance that would be available for Resident CR1 upon discharge.
An interdisciplinary team discharge summary dated December 26, 2024, revealed Resident CR1 is to be discharged home on December 27, 2024, with occupational therapy and physical therapy home health services. There was no documented evidence in the discharge summary to include and ensure safe resident medication administration upon discharge. There was no documented evidence in the discharge summary indicating the total amount of supervision and assistance that would be available to the resident upon discharge.
During an interview on January 15, 2025, at approximately 11:00 AM, the Director of Nursing (DON) and Director of Social Services (SS) confirmed Resident CR1 was to be discharged to her home. The DON and Director of SS were unable to provide documented evidence that Resident CR1 would receive the required care and services to ensure safe administration of medication upon discharge. The DON and Director of SS confirmed Resident CR1 had moderate cognitive impairment. The DON and Director of SS were unable to provide documented evidence of self-medication training or education. The Director of SS explained that Resident CR1 was discharged with a plan to receive home nursing care, but medication administration was not provided through the planned home health service. The DON confirmed Resident CR1's discharge was not against medical advice.
A clinical record review failed to provide documented evidence indicating Resident CR1 received any training or was able to safely self-administer her medications from her admission on December 10, 2024, through her discharge on December 27, 2024.
A physician discharge note dated December 27, 2024, indicating Resident CR1 arrived at the facility fairly altered and confused, did well in therapy, and was to be discharged home.
A medication review report dated December 27, 2024, revealed Resident CR1 was discharged with twenty-four medications, including Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 unit/ml (Insulin Glargine), with instructions to inject 30 units subcutaneously one time a day for diabetes.
During an interview on January 15, 2025, at approximately 1:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure a safe discharge plan is developed and implemented for each resident. The DON and NHA confirmed that Resident CR1 was hospitalized on December 29, 2024, two days after her discharge.
An interview with Resident CR1's resident representative on January 16, 2025, at 10:35 AM revealed Resident CR1 was discharged home on December 27, 2024. Resident CR1's resident representative indicated Resident CR1 lives at home alone and there was no plan in place to ensure Resident CR1 would be able to safely administer her medication upon discharge. Resident CR1's resident representative explained that Resident CR1 was admitted to the emergency department on December 29, 2024, related to the need for continued care.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 211.10 (c) Resident care policies.
28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 02/05/2025
1. Facility staff unable to retroactively correct as resident has been discharged.
2. DON/designee to perform an audit of current short-term residents to determine that a discharge plan has been initiated and includes measures to promote safe discharge.
3. DON/designee to provide education to IDT members on the process for initiation and coordination for safe resident discharges. Facility to incorporate an evaluation of resident specific discharge needs during the initial assessment period.
4. Facility to audit discharge plans for 3 residents per week X 4 weeks then 2 residents per week X 2 weeks to ensure safe discharge plans have been initiated and include measures to promote safe discharge.
5. Audit findings to be reported and reviewed at facility QAPI monthly X 3 to evaluate process improvement.
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