Failure to Implement Effective Discharge Planning and Coordination
Penalty
Summary
The facility failed to implement an effective discharge process for Resident #394, as evidenced by several deficiencies in planning and coordination. The resident, who was admitted following multiple fractures and required maximal to moderate assistance with activities of daily living, was discharged home after insurance coverage ended. Despite the resident's complex needs, including non-weight-bearing status, limited mobility, incontinence, and the need for intermittent self-catheterization, the facility did not develop a comprehensive discharge care plan, coordinate referrals to outside providers, or order the recommended medical equipment. Additionally, the discharge packet was incomplete, lacking a home medication list and other essential information at the time of discharge. The record review and staff interview confirmed that only an initial care conference was held, with no further documented planning or coordination for the resident's transition to home. The discharge paperwork was initiated late and was incomplete, and there was no evidence of proper coordination with home health agencies or vendors for necessary services and equipment. The physician's discharge summary outlined ongoing care needs and follow-up appointments, but the facility did not ensure these were addressed in the discharge process.