Failure to Establish Home Nursing Services Upon Discharge
Penalty
Summary
The facility failed to ensure that a resident had home nursing services established upon discharge. The resident, who was admitted with multiple diagnoses including infection following a procedure, surgical wound dehiscence, Alzheimer's, and anxiety disorder, was assessed as cognitively intact but required partial assistance with activities of daily living and mobility. The care plan identified deficits in self-care and mobility, and interventions were in place to support the resident's needs. Documentation indicated that the resident was discharged as independent with activities of daily living and was to receive home health care for medication delivery and wound care. However, interviews and record reviews revealed that the facility did not provide confirmation that the resident's discharge packet was sent to the home care agency or that the resident was accepted back for services. The home health agency reported that the resident's previous certification for services had expired and that they were not aware of a request for renewed services prior to or upon discharge. The agency also indicated that the resident's care needs had increased beyond what they could provide, and no evaluation or arrangements were made for the required medical services before discharge. The facility's discharge planning policy required social work staff to assist with referrals for post-discharge services, but this was not documented as completed for this resident.