Failure to Ensure Safe and Coordinated Discharge for Dependent Resident
Penalty
Summary
The facility failed to ensure a safe and coordinated discharge for a resident who required substantial assistance with activities of daily living (ADLs), including dressing, transferring, bathing, toileting, and was frequently incontinent of urine and bowel. Despite the resident's documented need for significant support and his own expressed concerns about the appropriateness of the discharge destination, facility staff informed him that he needed to leave due to insurance issues and being considered 'high functioning.' The resident was discharged to a sober living facility that did not provide any medical or physical assistance and required residents to be independent in all ADLs. Interviews with certified nursing assistants confirmed that the resident was always incontinent, never used the bathroom independently, and required help with showering, dressing, and transfers. The social services director acknowledged that the resident had voiced concerns about the lack of support at the sober living facility, but the case manager assured him that caregivers would be available, which was not accurate. Upon arrival at the sober living facility, staff there were surprised by the resident's care needs, as they had been informed he was independent and ambulatory. The facility representative stated they would not have accepted the resident had they known the extent of his needs. The resident was unable to receive necessary care at the sober living facility, leading to a 911 call and transfer to the hospital, after which he was readmitted to the skilled nursing facility. The facility's own policy required the care planning team to assess the availability and capability of caregivers at the discharge location and to address factors that could make the resident vulnerable to preventable readmission, which was not followed in this case.