Failure to Develop and Implement Adequate Discharge Plan for Resident Returning Home
Penalty
Summary
The facility failed to develop and implement an adequate discharge plan that addressed a resident's goal to return home, particularly in the event that alternative therapy services could not be obtained. The resident, who had diagnoses including heart failure, diabetes, unsteadiness, and an ostomy, required significant assistance with activities of daily living such as transferring, showering, and toileting. Despite the resident's and his wife's expressed desire for referrals to other facilities for continued therapy, the care plan did not include a focus area for discharge goals or planning related to these requests or for a safe return home if such services were unavailable. Clinical record review revealed that while the resident and his wife were informed of the end of skilled care and provided with a Notice of Medicare Non-Coverage, there was no documentation of a comprehensive assessment or discharge planning to address the resident's specific needs for a safe transition home. This included a lack of evaluation of transfer ability, safety and supervision needs, required equipment, the caregiver's capacity to provide necessary care, and the suitability of the home environment. The resident's wife ultimately took him to a hotel after discharge, as she was unable to get him into their home due to physical barriers, highlighting the absence of adequate planning for his return. Interviews with staff indicated that while some discussions occurred with the resident's wife regarding post-discharge care, there was no evidence of a formal home assessment or evaluation of the wife's ability to care for the resident. The facility's administrator confirmed that the only relevant policy was the bed hold policy and that no additional discharge planning documentation was present. The lack of a structured discharge plan and assessment resulted in the resident being discharged without assurance that his needs and preferences for a safe transition were met.