Failure to Ensure Safe and Appropriate Discharge for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia and lacking decision-making capacity was appropriately discharged. The resident was transferred to a Board and Care (B&C) facility without an Interdisciplinary Team (IDT) discharge meeting, prior discharge planning, or providing the resident’s Responsible Party (RP) and/or Family Member (FM) with a Notice of Proposed Discharge/Transfer 30 days prior to the transfer. There was no assessment of the resident at the time of transfer, no confirmation that the B&C facility received the resident’s contact information, and no medication or personal effects inventory list was sent with the resident. Documentation was incomplete, with missing signatures and contradictory information regarding whether discharge instructions and medication lists were provided to the RP or FM. The resident’s medical records indicated a diagnosis of dementia and depression, with assessments showing the resident was unable to make consistent and reasonable decisions and required assistance with activities of daily living. The care plan identified impaired cognitive function and the need for communication with the family and caregivers. Despite these needs, the discharge process did not involve the RP or FM, and there was no evidence of a completed discharge planning IDT meeting. The RP and FM were only informed of the discharge on the day it occurred, and neither was provided with the resident’s discharge location or adequate information about the transfer. After discharge, the resident was transferred from the B&C facility to an Extended Care Facility (ECF) and subsequently passed away without the knowledge of the RP or FM. Interviews with facility staff confirmed that required notifications and documentation were not completed, and the facility’s own policies regarding discharge planning and communication were not followed. The lack of proper discharge planning and communication resulted in the resident being discharged without the involvement or knowledge of her legal representatives, and her whereabouts and condition remained unknown to her family until after her death.