Failure to Ensure Safe Discharge Planning and Coordination of Post-Discharge Services
Penalty
Summary
The facility failed to implement its discharge planning process to ensure a safe discharge for a resident with multiple complex medical needs, including chronic respiratory failure, morbid obesity, and sleep apnea. The resident required substantial to total assistance with mobility and activities of daily living, was incontinent, and was receiving physical therapy, occupational therapy, and oxygen therapy. Documentation indicated that the resident was to continue receiving therapy and home health services, as well as oxygen therapy, after discharge. However, the discharge was not properly coordinated, as the social worker did not have documented evidence of arranging home care services or confirming acceptance by a home care agency. Additionally, the social worker did not coordinate ongoing oxygen therapy services, stating she was unaware of the resident's need for oxygen, despite documentation to the contrary. Family members reported that they were unable to reach the social worker after discharge and that promised wrap-around services were not provided. They also stated that they had to use an old oxygen concentrator from two years prior, and that the resident experienced falls at home post-discharge. The home care agency representative confirmed that services were verbally denied to the social worker, but there was no documentation of this communication. The lack of documented coordination and follow-through resulted in the resident being discharged without the necessary support and services to ensure a safe transition home.