Failure to Ensure Safe and Comprehensive Discharge Planning
Penalty
Summary
The facility failed to ensure comprehensive discharge planning for a resident who was being discharged, resulting in unmet care needs. The resident, who was cognitively intact, required a wheelchair for mobility, and needed daily medication via injections, was given a 30-day eviction notice. Despite the ongoing discharge planning, the care plan indicated the resident would remain in the facility until placement was found, but the resident was ultimately discharged to a local hotel that was not handicap accessible. The discharge notice cited that the resident no longer required skilled nursing services and exhibited behaviors that threatened the safety of others. Upon discharge, the resident's family member reported that the hotel room was not wheelchair accessible, lacked safety bars in the bathroom, and required navigating stairs, which the resident could not do. The resident was sent with medications, including insulin, but there was no documented assessment of the resident's ability to self-administer medications or manage insulin injections. Shortly after arrival at the hotel, the family member called 911 due to concerns about the resident's blood sugar, and the resident was subsequently admitted to the hospital. Interviews with facility staff revealed that no formal self-medication management assessment was completed, and there was no documentation of a physical therapy assessment or evaluation of the resident's ability to prepare meals or access prepared food. The administrator who arranged the hotel stay was unaware of the accessibility needs, and staff assumed the resident could manage independently without documented evidence. The discharge planning process did not ensure the resident's needs and preferences were met, nor did it prepare the resident for a safe transition.