Failure to Ensure Proper Discharge Procedures and Documentation
Penalty
Summary
The facility failed to ensure that a resident was not discharged without adequate justification and proper documentation. The resident in question had multiple diagnoses, including altered mental status, cognitive disorder, chronic kidney disease, hypertension, lack of coordination, muscle weakness, and hypothyroidism. Despite these conditions, the resident was able to perform activities of daily living independently and was sometimes able to express his needs. The care plan noted verbally aggressive behaviors and interventions such as social services visits and diversional activities, but did not include specific interventions to prevent physical aggression. On the day of the incident, the resident exhibited exit-seeking and aggressive behaviors, including attempting to leave the facility, turning over a table, and trying to throw objects. Staff administered Ativan and monitored the resident, but when behaviors continued, the DON instructed staff to contact the family. A family member, who was also a staff nurse, arrived and found the resident calm. The DON indicated that if the family did not take the resident home, the police would be called. The resident was discharged to the family member's home without a documented discharge plan, and the ombudsman was not notified. The discharge was not documented as necessary for the resident's welfare, nor was there evidence that the facility could not meet the resident's needs. Interviews with facility staff, including the Administrator and compliance nurse, confirmed that facility policy was not followed. There was no documentation from the physician regarding the need for discharge, no interdisciplinary discharge planning, and no assistance provided to the family in locating alternative placement. The facility's own policies require specific documentation and planning for discharges, which were not completed in this case. The ombudsman was not informed, and the discharge summary and medication release documentation were missing.