Failure to Ensure Safe Discharge Planning and Timely Provision of DME and Home Health Services
Penalty
Summary
The facility failed to ensure a safe and adequately prepared discharge for a resident with multiple complex medical conditions, including fractures, COPD, heart failure, diabetes, muscle weakness, and anxiety disorder. The resident, who was cognitively intact and dependent on a wheelchair for mobility, required substantial assistance with activities of daily living. Upon discharge, the resident was supposed to receive home health agency (HHA) services, palliative care, physical and occupational therapy, and durable medical equipment (DME) including a hospital bed and wheelchair. However, the discharge orders did not specify a wheelchair, and the Post-Discharge Plan of Care lacked the names and contact information for the HHA and DME providers, as well as details about the equipment needed. After discharge, the resident's son reported that neither the hospital bed nor the wheelchair had been delivered, and the HHA did not arrive as expected. The son had to independently search for contact information to follow up with the DME company and HHA, only to learn that the necessary services and equipment had not yet been approved. As a result, the resident, who was unable to stand, spent the first week at home mostly on the couch, and had to cancel a primary care appointment due to mobility issues. The hospital bed, wheelchair, and HHA services were not provided until approximately a week after discharge. Interviews with facility staff revealed that the discharge planning process was incomplete, particularly because the staff member responsible for filling out the Post-Discharge Plan of Care was not present on the day of discharge, and a floor nurse completed the documentation instead. There was also a lack of follow-up to ensure that the physician approved the DME and HHA orders prior to discharge. Documentation confirmed that the orders for the hospital bed and wheelchair were not signed by the physician until several days after discharge, resulting in delayed delivery of essential equipment and services.