Failure to Coordinate Discharge Services and Follow Discharge Policy
Penalty
Summary
The facility's Director of Social Services (DSS) failed to assist a resident in obtaining needed community services and did not follow the facility's Discharge Policy. The resident, who was cognitively intact and required supervision or assistance for mobility, had a care plan indicating a wish to be discharged home with arrangements for community resources such as home care, PT/OT, and nursing services. Physician orders were in place for discharge to home with VNS/PT/OT services. However, the resident was instead discharged to a boarding home, and there was no documentation of discussions with the resident or family about this change prior to discharge. The DSS admitted that the ordered VNS/PT/OT services were not initiated and expressed uncertainty about which facilities could accommodate these services, citing unfamiliarity with the area. The resident's physician was not informed of the discharge to a boarding home and confirmed that the ordered services were not provided. The facility's policies and the DSS job description require coordination of discharge planning and provision of medically related social services, which were not followed in this case.