Failure to Arrange Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that home health services were in place prior to the discharge of a resident who required ongoing care. The resident, who was admitted with paraplegia, cellulitis of the left lower limb, type 2 diabetes, and a need for assistance with personal care, had a documented goal to return to the community. The care plan and physician's note indicated that home health services were to be arranged upon discharge. However, the facility's records show that the referral to the home health agency (HHA) and the physician's orders were both dated on the day of discharge, with no confirmation that the HHA received or accepted the referral. Interviews with the facility's Social Services staff revealed that the resident initiated the discharge the day before leaving, and although the staff encouraged the resident to stay an additional day to allow time to arrange services, the resident agreed but was still discharged the following day. The Social Services staff could not provide evidence that the referral to the HHA was successfully sent or received. Additionally, the HHA representative confirmed that there were no records of the resident being admitted to their services or of receiving any orders for care.