Delay in Transition of Care Assistance for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to provide timely and appropriate transition of care assistance for a resident with complex medical needs, specifically related to lymphedema and Milroy's disease. The resident was admitted with multiple diagnoses, including lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder. A physician requested referrals to other facilities better equipped to address the resident's needs, but there was a significant delay of almost three months before any referrals were made. During this period, the resident's representative repeatedly requested updates on placement options but was informed that no progress had been made in locating a suitable facility, particularly one capable of providing necessary transportation and specialized care. Interviews with facility staff confirmed that the resident required a higher level of care than the facility could provide, and documentation showed that referrals were not initiated in a timely manner. The facility's assessment indicated that it provided care for residents with morbid obesity and bariatric needs, but did not address the specific requirements for lymphedema specialty care. The deficiency was identified during a review of records, interviews, and the facility assessment, affecting one resident out of two reviewed for discharge planning.