Failure to Provide and Document Safe Discharge Preparation
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a safe and orderly discharge of a male resident with multiple diagnoses, including cerebral ischemia, generalized anxiety disorder, hypertensive urgency, lack of coordination, and cognitive communication deficit. The resident was admitted to the facility and later discharged, but the records showed that key sections of the Minimum Data Set (MDS) assessment related to discharge were left blank, and a discharge MDS was not completed. The care plan indicated the resident's wish to return home and outlined steps for discharge planning, but there was no evidence of a physician's discharge order or comprehensive discharge planning documentation. The resident received a 30-day discharge notice due to failure to pay, and while the facility staff made referrals to other facilities, the resident refused these placements. On the day of discharge, the resident requested to be taken to a motel instead of a homeless shelter, and the facility van driver transported him to the motel, assisted with his belongings, and notified the administrator of the location. However, there was no follow-up by the facility to check on the resident's wellbeing or safety after discharge, and the resident's contact information was not documented for follow-up. Progress notes and interviews confirmed that the facility did not attempt to contact the resident post-discharge. Facility policy required discharge planning to ensure safe and appropriate transitions, including physician orders and communication with continuing care providers. Despite this, the facility did not complete the required discharge documentation, did not ensure a physician's order for discharge, and did not follow up with the resident after he left the facility. These actions and omissions resulted in a lack of documented preparation and orientation for the resident's discharge, as required by policy and regulation.