Failure to Ensure Safe Discharge Planning for Resident Requiring Wound Care
Penalty
Summary
The facility failed to ensure an effective discharge planning process for one resident who required ongoing wound care services. The resident, who was cognitively intact and had multiple diagnoses including heart failure, acute respiratory failure, type 2 diabetes, and acute hematogenous osteomyelitis, was discharged without confirmation that home health or skilled nursing wound care services were arranged. Documentation showed that the resident was initially planned to be discharged home with home health, skilled nursing wound care, and therapy services, but later records indicated a discharge to a homeless shelter with instructions that an outside provider would handle wound care. However, there was no evidence that these services were actually set up prior to discharge. Further review revealed that the resident's insurance coverage was inactive, and attempts to verify or utilize Medicaid benefits were unsuccessful. The social worker allowed the resident to keep facility equipment but did not update the discharge order or assessment to reflect the lack of skilled nursing services for wound care. The discharge assessment also lacked documentation of education on wound care or contact information for follow-up care. Staff interviews confirmed that the discharge paperwork was not updated to reflect the resident's actual discharge situation and that the resident was not provided with adequate information or resources for wound care after leaving the facility.