Failure to Ensure Safe and Person-Centered Discharge Planning
Penalty
Summary
The facility failed to ensure that two residents were provided with the necessary care and services to support a safe and person-centered discharge to the community. One resident, who was cognitively intact but required substantial assistance with all activities of daily living (ADLs) due to multiple sclerosis and muscle weakness, was discharged home without a documented care plan addressing discharge goals and needs. The resident's representative reported that there was no discharge planning until a few days prior to discharge, and that the facility did not arrange for home health services or complete the necessary Medicaid waiver in time. As a result, the resident was discharged without confirmed services in place, despite assurances that home health care would begin the same day. Documentation in the electronic medical record (EMR) did not show a completed plan for follow-up monitoring or contingency actions if services could not be started immediately. Another resident, also cognitively intact and dependent on staff for all ADLs due to quadriplegia and other complex medical needs, was discharged home without a thorough discharge plan. The resident's representative stated that the facility did not complete the waiver services application, did not provide a medication list or instructions, and did not arrange for a primary physician. After discharge, the resident experienced a seizure and was hospitalized, with the representative reporting that they were unaware the resident was supposed to take anti-seizure medications. Review of the EMR did not reveal documentation of a comprehensive discharge plan, updated care plan, or evidence that the resident or representative received necessary information regarding medications or care needs at discharge. Staff interviews confirmed that discharge planning was not always documented, and that in both cases, there was no formal discharge care plan or documentation of interdisciplinary team (IDT) involvement at discharge. The facility's own policy required that discharge planning begin on admission, be regularly updated, and be fully documented, including referrals and updates to the care plan. However, the records for both residents lacked evidence of these required actions, and the facility failed to ensure that the residents' needs and preferences were met or that they were prepared for a safe transition to the community.