Failure to Provide Medically Necessary Social Services for Discharge Planning
Penalty
Summary
The facility failed to provide medically necessary social services to assist a resident with the discharge process. The resident, who was cognitively intact and had multiple complex medical diagnoses including congestive heart failure, chronic respiratory failure, atrial fibrillation, and several mental health conditions, expressed ongoing interest in discharging from the facility. Care conference notes documented her uncertainty about discharge and her request to be asked about it at each meeting. The care plan indicated that staff would assist the resident and her family with information and resources related to discharge decisions. However, a review of the medical and discharge records over a one-month period revealed no documentation of assistance provided to the resident regarding her discharge planning, such as support with selling her house, visiting apartments, or purchasing a new home. Interviews with the social services staff confirmed that while the resident's discharge status was discussed quarterly, no further assistance or follow-up was provided even after the resident began actively seeking housing options and made appointments to view apartments. The resident reported that she independently managed all aspects of her potential discharge, including financial considerations and housing searches, without support from facility staff. The DON and Administrator acknowledged the lack of documentation and assistance provided, despite being aware of the resident's active efforts to discharge. The facility's policy required documentation of discharge planning and communication, which was not followed in this case.