Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to provide proper discharge planning for a resident with a history of visuospatial deficit and spatial neglect following a stroke, who had moderate cognitive deficits. The resident received physical, occupational, and speech therapy, with occupational therapy recommending 24-hour care and the use of a walker with a tray. Despite these recommendations, there was no documentation that the resident's physician was notified about the need for 24-hour care, nor was there evidence that the resident's potential caregiver received any training or confirmed their ability to provide the necessary care. Attempts to contact the resident's girlfriend, who was identified as a possible caregiver, were unsuccessful, and there was no documentation of alternative arrangements or notification to the physician regarding these barriers to a safe discharge. The discharge proceeded without ensuring that the recommended 24-hour care was in place, and the resident was sent home with home health services but without a confirmed or trained caregiver. The facility's own staff, including the Director of Rehab, Case Manager, and Director of Nursing, acknowledged the lack of documentation and coordination regarding caregiver training and notification of the physician about the occupational therapy recommendations. The facility's policy required that residents only be discharged when it was safe and appropriate, but this was not followed in this case.