Failure to Ensure Safe and Proper Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
The facility administrator failed to provide consistent oversight to ensure that the Social Services Department and interdisciplinary team (IDT) implemented the facility's policy and procedure for safe transfer and discharge of a resident with severe cognitive impairment. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, unsteadiness, history of falls, diabetes, hearing loss, psychotic and mood disturbances, and anxiety, was discharged to a board and care facility without proper IDT evaluation or documentation of a discharge meeting with the responsible party (RP). The responsible party, identified as the resident's granddaughter, was not given adequate notice, was not involved in the discharge planning, and did not receive necessary information such as discharge orders, medication instructions, or the opportunity to collect the resident's personal belongings. The discharge process was initiated by a staff member who was no longer serving in the Social Services Director (SSD) role, but rather as a certified nursing assistant (CNA) and activity assistant (AA). This staff member completed the notice of transfer/discharge without a documented discussion or agreement from the medical doctor or IDT, and based the decision on her own opinion that the resident was a danger to others. The current SSD and the administrator both confirmed that the proper process was not followed, and that the SSD should have been responsible for coordinating the discharge in collaboration with the IDT. Additionally, the facility failed to send critical documents, such as the POLST (physician orders for life-sustaining treatment), to the receiving board and care facility. The responsible party was not notified when the board and care staff assessed the resident, nor was she given the chance to review the new placement prior to discharge. Following the transfer, the resident eloped from the board and care facility multiple times, and the board and care facility had to implement additional safety measures. The facility's actions did not adhere to its own policy requiring a 30-day written notice and proper communication with the resident or responsible party regarding the transfer or discharge.