Failure to Ensure Ongoing Discharge Planning and Safe Transfer
Penalty
Summary
The facility failed to ensure an ongoing discharge planning process for a resident with intact cognition who was reviewed for discharge. The resident's care plan indicated no plans for discharge, and the care conference review form left the discharge potential section blank. Although a Notice of Transfer or Discharge form was prepared, it was not signed by the resident or their representative. Progress notes for the period leading up to the proposed discharge date lacked documentation regarding the resident's discharge plan. The resident was later sent to the emergency room for a psychiatric evaluation and subsequently discharged to an inpatient psychiatric facility, with no evidence of a documented discharge plan in the progress notes during this period. Interviews with facility administrators revealed inconsistencies regarding the discharge process, including whether involuntary discharge paperwork was completed and whether the resident received appropriate notifications. The facility's policy required orientation and preparation for transfer or discharge to ensure safety and minimize anxiety, but there was no documentation that these steps were followed. The resident ultimately did not return to the facility, and administrators were unclear about the resident's final placement or the completion of required discharge procedures.