Failure to Coordinate Discharge Planning and Communication for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure proper discharge planning and coordination for a resident with complex medical needs. The resident, who had a history of hemiplegia, hemiparesis, cerebral infarction, primary thrombophilia, depression, aphasia, seborrheic dermatitis, dysphagia, gastrostomy, hyperlipidemia, glaucoma, and coronary artery disease, was discharged to an assisted living facility (ALF) without adequate communication or preparation. The discharge process did not include regular re-evaluation of the discharge plan, nor was there effective coordination with the resident's representative. The resident's legal guardian participated in initial goal setting, but the overall discharge goal remained unclear, and no referrals were made to local contact agencies as required. During the discharge process, the facility did not ensure that the ALF was notified of the resident's gastrostomy tube, nor did it provide the resident with a supply of hydroxyzine, a medication prescribed for itching. The ALF and care coordinator reported a lack of communication from the facility's Director of Social Services (DSS), resulting in the ALF being unaware of the resident's g-tube and the need for home health services. The resident arrived at the ALF with the g-tube still in place, no home health services arranged, and without all necessary medications. The ALF had to arrange for the removal of the g-tube at a hospital and struggled to set up home health due to insurance issues. Interviews and record reviews revealed that the DSS did not follow up with the resident, family, or ALF after discharge, and did not provide necessary documentation or coordination for the resident's ongoing care needs. The facility's policies required discharge planning to begin at admission, regular updates to the care plan, and communication with all parties involved, but these steps were not consistently followed. The lack of follow-up and incomplete discharge preparation led to significant gaps in the resident's transition to the ALF.