Failure to Ensure Safe Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of a resident who was discharged home. The Administrator (ADM) and Director of Nursing (DON) directed staff to discharge a resident with a diagnosis of dementia, confusion, and altered mental status, who had no power of attorney (POA), to her home without confirming appropriate supervision or care arrangements. The Interdisciplinary Team (IDT) did not notify the nurse practitioner (NP) or physician (MD) about the resident's discharge home alone and without services. The discharge planning process did not include a thorough assessment of the resident's cognitive and functional abilities at the time of discharge, and the discharge Minimum Data Set (MDS) was incomplete and unsigned by authorized personnel. The resident's care plan indicated she required assistance with activities of daily living (ADLs), supervision for mobility and transfers, and was at risk for falls due to her cognitive impairment. Despite these documented needs, the resident was discharged via a ride-share service to an apartment that, according to family, lacked electricity and was unsanitary. The family member who was listed as an emergency contact expressed concerns about the resident's ability to live alone and the unsafe home environment, but these concerns were not adequately addressed by the facility. The facility did not ensure that home health services or necessary durable medical equipment were arranged prior to discharge, and other potential family contacts were not involved in the discharge planning process. Interviews with facility staff and family revealed that the discharge was driven by the end of the resident's insurance coverage, and the ADM did not investigate the home environment or seek alternative family support before proceeding. The resident arrived home without a walker or wheelchair and was left alone, with the family member only able to assist after the fact. The NP later confirmed that the resident's confusion was progressive and that she required supervision if discharged home. The facility's actions resulted in the resident being returned to an unsafe environment without adequate planning or support, as documented by multiple staff and family interviews.
Removal Plan
- Residents and family members will be instructed to provide their own transportation upon discharge. Courtesy transportation will no longer be provided.
- Discharge paperwork will be presented to the power of attorney, responsible party, and/or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge.
- A discharge summary/plan of care will be provided to the cognitively intact resident, responsible party, and/or power of attorney.
- Post discharge services such as home health will be set up prior to discharge.
- Physicians and NPs will be notified of discharges to address resident's needs.
- An in-service will be completed with the Administrator by the Regional President of Operations that details the entire discharge planning process including the completion of discharge summaries, contacting RP/POA's, confirmation of transportation, and home health set up confirmation.
- An in-service will be completed with the Social Worker and Case Manager by the Administrator that details the entire discharge planning process including the completion of discharge summaries, contacting RP/POA's, confirmation of transportation, and home health set up confirmation.
- An in-service will be completed with the IDT by the Administrator regarding the completion of the discharge summary, notifying the Physicians and NPs of discharges to address resident's needs, providing discharge paperwork to the power of attorney, responsible party, and/or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge.
- All discharges will be reviewed by the IDT in a weekly standards of care meeting to ensure care/summary was completed, Discharge Summary completed, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed.
- All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/or administrator will contact the ombudsmen and seek assistance if needed for guardianship.
- The DON/Designee will review all discharge orders for upcoming discharges for completion.
- The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs.
- The Administrator/Designee will audit all discharges for discharge summaries, discharge location, means of transportation, and confirmation of home health.
- A Quality Assurance and Performance Improvement review of the removal plan will be completed with the Medical Director for agreement with this plan.