Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
A deficiency occurred when a facility failed to ensure a safe and appropriate discharge for a resident with a complex medical and psychiatric history, including epilepsy, encephalopathy, anxiety disorder, and schizophrenia. The resident had fluctuating capacity to make medical decisions, was at risk for falls, and required assistance with ambulation, medication management, and activities of daily living. Despite these needs, the resident was discharged to an unlicensed board and care (B&C) facility that could not provide the necessary level of care, including ambulation assistance, epilepsy management, or medication administration and storage. The facility did not follow its own discharge and transfer policy and procedures, as the interdisciplinary team (IDT) did not conduct a discharge planning meeting prior to the resident's transfer. Key departments, including nursing, activities, and rehabilitation, were not notified or involved in the discharge planning process. The resident's care plan, which required coordination with rehabilitative therapies and community resources, was not implemented, and the discharge planning review form was incomplete. The facility also failed to verify the B&C's license, assess the appropriateness of the discharge location, or provide a hand-off report to the receiving facility regarding the resident's medical conditions and care needs. As a result of these failures, the resident experienced a series of adverse events after discharge, including a fall with head injury at the B&C, subsequent hospitalization, transfer between multiple facilities, and an episode of elopement that led to police intervention and further hospitalization. Interviews with facility staff and external providers confirmed that the resident's needs exceeded the capabilities of the B&C, and that critical steps in the discharge process, such as medication reconciliation, communication with the receiving facility, and post-discharge follow-up, were not performed.
Removal Plan
- The Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer policy and procedures. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility's Director of Nursing (DON)/Director of Staff Development (DSD)/Designee including the new processes implementation related to identified concerns to all active license nurses and IDT members.
- The facility has 30 licensed nurses and 24 have been provided with in-service and education. Facility does not have a licensed staff on vacation, leave nor FMLA (Family and Medical Leave Act).
- The Social Services consultant worked 1:1 with the Social Services Director (SSD). The SSD completed the Discharge Planning Review form, sections 1 (Discharge Goals/ General Information) A (Discharge Goals/ General Information) & B (Caregiver Responsibilities), 2 (Self Care Evaluation and Equipment) Q (equipment and supplies), Contacts and Sign and Date of the Discharge Summary, for training purposes.
- The facility DON and Medical Records initiated an audit to residents who have been discharged to a lower level of care in the past 30 days to ensure proper discharge planning was conducted prior to discharge with resident/responsible party, an IDT meeting was conducted prior to discharge, an endorsement of the resident's medical history and medication reconciliation was provided to receiving facility. No similar issues were identified.
- For those residents who lack capacity or with fluctuating capacity, the Office of Public Representative (OPR) will be contacted by the facility's SSD/Designee to act as an advocate in the discharge plan IDT prior to the discharge to ensure location is safe and appropriate given the residents' conditions. If the OPR does not wish to participate, the facility IDT in conjunction with the physician will hold an IDT meeting to review and document appropriateness.
- For those residents who lack capacity or with fluctuating capacity and have resident representatives, an IDT meeting will be held with the responsible party to review and discuss the discharge location for safety and appropriateness.
- Discharge planning will begin on the residents' admission to the facility.
- The Attending Physician and the IDT will review the residents' progress and determine a possible discharge date and document in resident's health record.
- The facility Admin notified Resident 1's attending physician, by phone of the concerns related to the resident's transfer to the Board and Care, the fall sustained and readmission to the hospital.
- The facility Admin notified facility Medical Director by phone of the Immediate Jeopardy that was issued, deficient practice and plan to correct.
- The facility Admin initiated a QAPI (Quality Assurance and Performance Improvement) regarding the Transfer and Discharge of residents.
- The facility staff will assist the physician and the resident to obtain medications after discharge from the facility. When discharged, remaining medications that have been administered to the resident while in the facility may be provided to the resident at the time of discharge if the medications were specifically ordered to be sent home with the resident.
- The Licensed Nurse will assure that the medication orders are reviewed with the resident and/ responsible party and explanation of all discharge medication orders occur at the time of discharge and documented on the resident's health record.
- The facility will ensure that the resident receives adequate follow-up including the ability to have a physician's prescription available to procure drug supply immediately after discharged from the facility and conduct a proper endorsement of resident's ordered medications and discharge instructions to the receiving facility and documented on the resident's health record.
- The facility's SSD and Admin located Resident 1. Resident 1 resided in Skilled Nursing Facility (SNF) 2 and was doing well.
- The facility's SSD/Designee will conduct a post discharge follow up call within 72 hours to ensure that the resident has transitioned adequately to the new facility/location moving forward.
- Newly hired licensed nurses/IDT will be educated by the facility's DON/DSD on facility's P&P pertaining to Discharge and Transfer of residents during their orientation and as needed.