Failure to Arrange and Prepare for Safe Discharge
Penalty
Summary
A resident with significant medical needs, including a recent surgical amputation, immunodeficiency, diabetes, and open wounds requiring complex wound care, was discharged from the facility without a comprehensive discharge plan or proper arrangements for home care services. The resident's care plan did not include any discharge focus, goals, or interventions, and the Minimum Data Set lacked a cognitive assessment. Although the provider ordered skilled nursing and occupational therapy for the home, there was no evidence that these services were arranged prior to discharge. The facility's social worker, who was responsible for setting up home care services, was not present at the time of discharge and did not begin searching for agencies until after the resident had already left. Multiple home care agencies were contacted after the discharge, but all denied services. The resident was not contacted by the facility following discharge, and there was a lack of communication regarding which agency would provide the necessary care. Nursing staff assumed that home care services were in place, but there was no confirmation or follow-up. As a result, the resident went home without the ordered home care services, leading to worsening of his wounds and subsequent hospital admission. The facility's policy required a post-discharge plan developed by the interdisciplinary team, including arrangements for follow-up care and support, but this process was not followed. Interviews with staff revealed gaps in training and understanding of discharge procedures, and the resident was not adequately prepared or oriented for a safe transition home.