Failure to Provide Required Medical Equipment at Discharge
Penalty
Summary
The facility failed to develop and implement a comprehensive discharge plan that addressed all of a resident's needs prior to discharge. Specifically, a resident with a diagnosis of sleep apnea, who required nightly use of a CPAP device and a shower chair, was discharged to an Adult Family Home without these essential items. The resident's records documented consistent use of the CPAP device during their stay, and orders were in place for both the CPAP and a shower chair. However, the discharge summary and plan did not include arrangements for these items, and no orders were made to ensure their availability upon discharge. Interviews with facility staff revealed a lack of coordination and communication regarding the ordering of necessary durable medical equipment. The social services director acknowledged that the order for the shower chair was missed and believed nursing was responsible for ordering the CPAP, but neither item was provided at discharge. The resident care manager was aware that the equipment did not accompany the resident but was unclear about the reasons. The facility's policy required interdisciplinary collaboration to identify and arrange for discharge needs, but this process was not followed, resulting in the resident being discharged without critical equipment.