Failure to Ensure Safe and Orderly Discharge for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with multiple complex medical conditions, including chronic respiratory failure requiring continuous oxygen, severe malnutrition, COPD, opioid dependence, and mental health disorders. The resident was discharged without arrangements for home health or ongoing oxygen services, and the exact discharge location was unknown to facility staff. Documentation shows that the resident was informed of an immediate discharge due to non-payment and was given a short timeframe to leave, with the threat of police involvement if she did not comply. The resident was provided only a four-hour oxygen tank and had to use her own nasal cannula from the facility. Interviews with staff confirmed that the resident was not offered the opportunity to appeal the Medicaid noncoverage decision, and that necessary services for a safe discharge were not arranged. The resident reported that after her oxygen supply ran out, she was hospitalized for 24 hours and subsequently became homeless. The Ombudsman and Medical Director both confirmed that the facility did not make proper arrangements for a safe discharge, including ensuring a safe destination and provision of required medical services such as home health and oxygen.