Failure to Ensure Discharge Services for Resident with ADL Needs
Penalty
Summary
The facility failed to ensure that appropriate discharge services were in place prior to discharging a resident with significant care needs to an independent senior housing apartment. The resident, an elderly female with diagnoses including osteoarthritis, gait and mobility abnormalities, type 2 diabetes, unspecified dementia, and cognitive communication deficits, required staff assistance with ambulation, was incontinent, and needed help with activities of daily living (ADLs). Despite these needs, the resident was discharged without a documented discharge plan addressing her required services, and there was no confirmation that home health or caregiver services were arranged prior to her return to independent living. Multiple staff interviews revealed a lack of clear communication and coordination regarding the resident's discharge needs. The Social Service Director (SSD) admitted to not knowing the type of setting the resident was being discharged to and did not ensure that caregiver services or home health were set up before discharge. The Restorative Nurse and Director of Therapy both expressed concerns about the resident's safety and appropriateness for independent living, noting her need for supervision, incontinence, and lack of safety awareness. The senior housing staff repeatedly informed the facility that they did not provide any care or assistance with ADLs, and that all necessary services should be arranged prior to discharge. However, these services were not confirmed to be in place, and the resident was left without adequate support. As a result of these failures, the resident was found in her apartment soiled in urine and feces, unable to get out of bed, and appeared to have been in bed since the previous day. Documentation showed that while referrals for home health and therapy were made, there was no follow-up to ensure these services were initiated, and critical information such as the resident's phone number was not communicated to service providers. The facility's own discharge policy requires the interdisciplinary team to review and develop a discharge plan based on the resident's needs, but this was not completed in this case.