Failure to Document and Follow Up on Discharge Referrals
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident with complex medical needs, including quadriplegia, pressure ulcer, osteomyelitis, bipolar disorder, and anxiety disorder. The resident had an active care plan indicating a desire to transfer to a skilled nursing facility (SNF) closer to family. Documentation showed that only one referral was made to a nearby SNF at the family’s request, with no follow-up or record of the SNF’s response. There was no evidence of additional referrals or follow-up actions documented in the resident’s record over several months, despite ongoing requests from the resident and family. Interviews with the resident, family member, and social worker (SW) revealed that the family repeatedly requested referrals and follow-up, but the SNF in question had not received any referrals, and the SW did not return calls. The SW stated that she sent several referrals but did not document the names or contact information of the SNFs, only the cities, and did not follow up with the facilities after sending referrals. The administrator confirmed that while referrals were sent, there was no consistent documentation or follow-up process in place. This lack of documentation and follow-up resulted in the resident’s discharge preferences and needs not being adequately addressed.