Failure to Ensure Safe and Appropriate Discharge for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an appropriate and safe discharge for a resident with severe cognitive impairment and a history of brain tumor and craniotomy. The facility did not follow physician discharge orders, as the resident was discharged to a hotel without home health services being established, despite orders for home health RN, PT, and OT. The required 30-day discharge notice was not provided in advance but was instead given at the time of discharge, depriving the resident of the opportunity to appeal. Additionally, the facility did not develop or document post-discharge follow-up for a neurology referral, and there was no physician discharge summary in the resident's medical record. Further review revealed that the MDS discharge assessment was incomplete and not submitted, and cognition and mood assessments were not performed. The resident, who had documented severe cognitive deficits and required maximum cues for memory and following directions, was found confused and non-verbal after discharge, leading to hospitalization. Facility staff, including the Social Services Director, MDS Coordinator, DON, and Administrator, confirmed these deficiencies and acknowledged that the discharge was not conducted safely or in accordance with facility policy and federal requirements.