Failure to Provide Safe and Comprehensive Discharge Planning
Penalty
Summary
Facility staff failed to provide a safe and comprehensive discharge for a resident with diagnoses including Parkinson's disease and alcoholism. The resident's clinical record documented ongoing alcohol abuse, multiple falls, unsteady gait, and unintentional weight loss. Despite these complex needs, the discharge process lacked a clear and coordinated plan, with the resident's substance abuse issues not addressed in the discharge planning. The resident was issued a 30-day notice of discharge due to nonpayment, but the notice did not specify a discharge date or destination, and there was no evidence in the record of when the resident received this notice. Interviews with facility staff revealed that the social services team was not fully involved in the discharge planning until the final days before discharge. The social worker assigned to the case was instructed by an administrative staff member to find placement for the resident, including the option of paying for a hotel stay, but expressed discomfort with this plan and attempted to find a shelter instead. The discharge plan was changed multiple times, and the final discharge location was not clearly documented. The social worker was not aware of the resident's alcohol dependency and stated that substance abuse counseling should have been included in the discharge plan, but it was not. Facility policy requires that discharge notices include the discharge date and destination, and that significant changes to the plan be communicated with updated notices. The policy also requires a post-discharge plan of care developed with the resident's participation, including orientation to the new environment and documentation of discussions with the resident or their representative. In this case, the documentation did not include a clear discharge plan, discharge location, or evidence of a safe and orderly transition, particularly in light of the resident's medical and behavioral needs.