Failure to Confirm Home Health Services Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure that a follow-up for needed Home Health (HH) services was completed and confirmed prior to the discharge of a resident who required ongoing care for diabetes management. The resident, who had moderately impaired cognition and required moderate assistance with personal hygiene and toileting, was diagnosed with diabetes mellitus and end stage renal disease. The Social Services Director (SSD) sent a fax request for a Home Health Registered Nurse (HH RN) to visit the resident at home but did not call to confirm the service with the HH agency before the resident was discharged. The resident was discharged home with a family member before confirmation of the HH RN visit was obtained. The facility's own policy and the Director of Social Services' job description required coordination and confirmation of follow-up care and services prior to discharge. The lack of timely confirmation of HH services prior to discharge resulted in a failure to ensure continuity of care for the resident's diabetes management needs.