Failure to Ensure Safe Discharge Plan for Resident
Penalty
Summary
The facility failed to develop and implement a safe discharge plan for a resident, identified as Resident CR1, who was admitted with chronic kidney disease and traumatic brain injury. The resident was moderately cognitively impaired, as indicated by a BIMS score of 8. A progress note highlighted the need for 30 hours a week of caregiver support, and physical therapy discharge recommendations included significant supervision and assistance due to impaired cognition and safety. However, the clinical record lacked documentation of the total amount of supervision and assistance available upon discharge. The interdisciplinary team discharge summary indicated that Resident CR1 was to be discharged home with occupational and physical therapy home health services. However, there was no documented evidence ensuring safe medication administration upon discharge, nor was there evidence of self-medication training or education provided to the resident. The Director of Nursing and Director of Social Services confirmed the absence of a documented plan for safe medication administration, despite the resident's moderate cognitive impairment and the discharge plan not being against medical advice. Upon discharge, Resident CR1 was sent home with 24 medications, including insulin, without a plan for safe administration. The resident's representative confirmed that CR1 lived alone and was hospitalized two days after discharge due to the need for continued care. The facility's failure to ensure a safe discharge plan, including medication administration, led to the resident's hospitalization shortly after discharge.
Plan Of Correction
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.