Failure to Ensure Safe and Appropriate Discharge for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, poor memory, poor insight and judgment, and multiple medical diagnoses was discharged from the facility without adequate preparation or safeguards. The facility failed to update the resident's fall risk assessment for two consecutive quarters prior to discharge, despite policy requiring quarterly assessments. Interviews with the DON confirmed that these assessments were missing from the clinical record. The resident's discharge Minimum Data Set (MDS) was inaccurately coded, as it understated the level of assistance required for activities of daily living (ADLs) such as bathing, dressing, and personal hygiene. Multiple CNAs reported that the resident was dependent or required maximal assistance for these tasks, but the discharge MDS indicated only moderate assistance or supervision. The MDS director confirmed the inaccuracy after reviewing the documentation. Additionally, the facility did not provide a written discharge notice or develop a discharge care plan for the resident, nor were there discharge notes on the day of discharge. The social services director stated that discharge notices were only given to short-term residents, not long-term residents. The facility also failed to verify the license and care capabilities of the discharge placement, which was later found to be an unlicensed independent living facility. The resident was discharged to this setting, where she experienced a fall and was subsequently sent to acute care. The acute care facility determined that the discharge placement was inappropriate and refused to return the resident there.