Failure to Implement Discharge Planning and Documentation for Safe Resident Transitions
Penalty
Summary
The facility failed to implement its discharge planning process for two residents, resulting in unsafe discharges and placing the residents at health and safety risks. For both residents, records lacked discharge care plans, interdisciplinary team (IDT) meeting notes addressing discharge planning, and documentation of referrals to or acceptance from shelters and home health agencies. Interviews with facility staff confirmed that required documentation and resident participation in discharge planning were missing, and that much of the discharge process was conducted verbally without written records. One resident had severe cognitive impairment, dementia with agitation, and no family or income. Despite expressing a desire to return to his hometown and a lower level of care, his record did not contain an active discharge plan, IDT notes, or evidence of referrals to community resources. He was discharged to a shelter without documented preparation or coordination, and was later readmitted to the facility due to inability to care for himself. Shelter staff reported rarely receiving referrals for elderly skilled nursing residents and noted that such residents are considered a red flag for admission. The second resident, with alcohol-induced dementia and moderate cognitive impairment, was also discharged to a shelter without documentation of an active discharge plan, IDT notes, or evidence that he was informed about his destination or provided with community resource information. There was no assessment of his ability to manage in the community without income or support. After discharge, he was found sleeping outside a liquor store, was hospitalized, and was described as gravely disabled and homeless. Facility policy required a post-discharge plan and resident preparation, but these steps were not documented or followed for either resident.