Failure to Provide Complete Post-Discharge Plan of Care
Penalty
Summary
The facility failed to ensure that a resident received a comprehensive post-discharge plan of care containing all necessary information for the continuation of care after discharge. The resident, who had a complex medical history including a left above-the-knee amputation, COPD, and cirrhosis with ascites, was discharged without complete documentation regarding responsible party contact information, activity levels, equipment and supplies, home health agency details, wound care instructions, ombudsman information, follow-up appointments, and pharmacy information. The discharge summary also lacked documentation of discharge diagnosis and prognosis. Interviews with facility staff revealed that while the case manager and social service staff attempted to coordinate discharge planning, there were gaps in communication and follow-through. The case manager did not make follow-up appointments as ordered, nor did she discuss the possibility of applying for additional services through Medi-Cal. The home health agency and insurance care coordinator were notified of the resident's needs, but no appointments were scheduled prior to discharge. The resident's family was left without clear instructions, leading them to contact the facility for advice when the resident experienced swelling in his leg after discharge. As a result of the incomplete discharge planning and lack of necessary information, the resident's family sent him to the emergency room within 24 hours of discharge. Facility policy and job descriptions indicated that nursing services and case management were responsible for preparing and communicating the post-discharge plan, but these requirements were not met in this instance, resulting in a breakdown in the continuity of care.