Failure to Ensure Safe and Adequate Discharge Planning
Penalty
Summary
The facility failed to provide sufficient preparation and orientation for a safe and orderly discharge for one resident. The interdisciplinary team (IDT) did not follow up on the care conference recommendations regarding discharge planning during the resident's admission. Although the care plan and discharge planning review identified that the resident lived alone and would require a caregiver (CG) for safety, there was no documented evidence that these recommendations were fully implemented or followed up. The resident had multiple diagnoses, including infrarenal abdominal aortic aneurysm, type II diabetes mellitus, muscle weakness, and major depressive disorder, and was noted to have moderately impaired cognitive skills and fluctuating capacity to make decisions. The resident's family expressed concerns about his safety living alone, and the general acute care hospital social worker recommended discharge to an assisted living facility (ALF) due to the resident's comorbidities and home situation. Despite these concerns, the resident was discharged home alone with home health services, and there was no documentation confirming that a caregiver was arranged or that ALF was presented as an option. Interviews with staff revealed that while the resident was provided with brochures for caregiver agencies, he stated he could not afford a caregiver, and no information about ALF was given. The facility's policy required documentation of discharge planning and arrangements for post-discharge care, but the medical record did not reflect adequate follow-up or evidence that the necessary care and services were provided upon discharge.