Failure to Ensure Safe Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, dementia, schizophrenia, and a history of falls was discharged from the facility without proper discharge planning or interdisciplinary team (IDT) involvement. The resident required significant assistance with activities of daily living, was on antipsychotic and nerve pain medications, and had a care plan indicating the need for one-on-one supervision due to poor safety awareness. Despite these needs, there was no evidence of an IDT meeting or discharge care plan prior to the resident's discharge, and the resident's physician was not notified or involved in the discharge decision. The discharge location was a private home, not an assisted living or dementia care unit, and was arranged by a facility marketer without verification that the location could meet the resident's needs. The address provided to the family could not be verified, and the landlord of the home was not a healthcare professional and was unaware of the resident's medical requirements. The resident's family was not involved in selecting the discharge location, and the facility failed to notify the Local Contact Agency or the Ombudsman of the discharge. No discharge documents or information were provided to the receiving location, and there was no follow-up to ensure the resident was safely settled. Upon arrival at the home, the resident was found to be in poor condition, non-verbal, and later became unconscious, requiring emergency transfer to a hospital where a urinary tract infection and altered mental status were identified. The facility did not document the medications sent with the resident, did not ensure a responsible party was available to administer medications, and failed to provide necessary education or instructions regarding medication administration. The facility's actions were not in accordance with its own policies and procedures for safe discharge, notification, and documentation.