Failure to Coordinate Home Health Services and Provide Complete Discharge Documentation
Penalty
Summary
The facility failed to coordinate Home Health (HH) services, provide a medication list, and complete discharge instructions for one resident who was discharged home. The resident had a history of subluxation of the left shoulder, falls, difficulty walking, and chronic pain, and required setup for showers and supervision for ambulation. The discharge summary indicated the resident would require HH services for physical and occupational therapy as well as RN services. However, the Discharge Instruction Form did not include the HH agency or contact information, and there was no documentation of a physician-signed medication list in the resident's medical record. Interviews with facility staff confirmed that Social Services was responsible for arranging HH services and that the discharge instruction form should have included the HH agency name, contact information, and a complete medication list. Staff acknowledged that the Discharge Instruction Form for the resident was incomplete and that there was no documentation of the HH agency or contact information. Additionally, staff were unable to provide documentation of a signed medication list or evidence that HH services had been arranged for the resident at the time of discharge.