Failure to Follow Discharge Planning and Unplanned Discharge Procedures
Penalty
Summary
The facility failed to follow its own policies and procedures for discharge planning and unplanned discharges for multiple residents. For three residents who left the facility unexpectedly, there was no documentation that Adult Protective Services (APS) were notified or that any attempts were made to locate the residents after they left. In one case, a resident left the facility with all her belongings and was later found at a local fast-food restaurant in a disheveled state, but there was no evidence that the facility contacted emergency contacts, APS, or the police, nor did staff attempt to locate her. Similarly, two other residents left the facility, one after refusing to sign an Against Medical Advice (AMA) form, and no further action was taken by the facility to ensure their safety or notify appropriate authorities. Additionally, the facility did not provide adequate discharge planning for three residents who expressed a desire to return to the community or move to a less structured environment. Care plans and progress notes indicated that these residents were cognitively intact and had self-sufficiency skills, yet there was no evidence of active discharge planning or social service involvement to assist them in transitioning out of the facility. In interviews, these residents reported that although they had communicated their wishes to leave, they were not receiving help from the facility to facilitate their discharge. The Social Service Director and other staff confirmed that discharge planning was not initiated unless specifically requested by the resident, and that no active discharge plans were in place for the residents who had expressed a desire to leave. The facility's own policies require the involvement of social work staff in assessing discharge potential and coordinating community services, but documentation and staff interviews revealed that these procedures were not followed. The lack of action and documentation regarding both planned and unplanned discharges resulted in a failure to ensure safe and appropriate transitions for the affected residents.