Failure to Ensure Safe Discharge Planning
Penalty
Summary
The facility failed to ensure a safe discharge for one resident who was readmitted with congestive heart failure and delusional disorders. The resident was discharged to a family home that lacked running water, electricity, and heat, and was infested with rats. The primary physician reported not being included in discharge planning or informed of the discharge, and the former Social Services Director confirmed discouraging the discharge due to unsafe conditions. Clinical records showed an earlier interdisciplinary team (IDT) meeting determined it was unsafe to discharge the resident, and a social history review documented the resident's preference to return home despite the risks. However, there was no documented evidence that the IDT met to ensure a safe discharge at the time of the resident's release, and facility leadership could not provide additional information regarding the unsafe discharge.