Failure to Ensure Safe and Appropriate Discharge for High-Needs Resident
Penalty
Summary
A facility failed to ensure a safe and appropriate discharge for a resident with dementia and dysphagia who required constant supervision and a pureed diet. The resident was discharged to an unlicensed room and board facility that did not provide caregivers or understand the resident's medical and dietary needs. The facility did not verify whether the receiving environment could meet the resident's care requirements, and there was no documentation that the facility communicated with the receiving location to confirm its suitability. The resident's care plans indicated significant needs, including 1:1 supervision for elopement risk, assistance with all activities of daily living, and a specialized diet due to swallowing difficulties. Despite these documented needs, the discharge process relied on a placement agency that did not assess the resident in person or ensure the receiving facility was licensed or capable of providing the required care. The Social Services Director admitted to not verifying the receiving facility's ability to meet the resident's needs and assumed that such facilities would not accept residents they could not care for. Upon arrival at the unlicensed room and board, the owner was unaware of the resident's dietary restrictions and did not provide 24-hour care or supervision. The resident did not have family support or in-home services at the new location. Within a week, the resident was transferred to a hospital due to concerns about care. The facility did not have a specific policy or procedure for managing safe discharges, and the only relevant policy referenced the need to consider the resident's needs, choices, and best interests when determining transfer locations.
Removal Plan
- The Social Service Director (SSD) and the Case Manager (CM)/Discharge Planner (DCP) reviewed residents scheduled for possible discharge to ensure that each resident was appropriately assessed for discharge placement and that the receiving facility will be able to meet the residents' needs.
- The SSD and CM/DCP reviewed residents who were discharged and ensured that each resident was safely discharged and the receiving facility was able to meet the residents' needs.
- The Director of Nursing (DON) conducted an in-service to the SSD and CM/CDP regarding appropriate discharge placement to ensure that residents are discharged to a safe location that can meet their needs.
- The receiving facility will send a representative to assess the resident's current condition and plan of care, which includes evaluation of diet, medications, functional abilities (such as transfers, bed mobility, and ambulation), and cognitive status.
- A checklist was created to identify the residents' needs and will be used to verify and acknowledge that they can manage the care of the resident.
- The SSD will continue to conduct admission assessments with initial plans for discharge in collaboration with IDT and during their stay at the facility and coordinate with the resident or the responsible party for changes in the discharge plans and provide assistance as needed.
- The SSD and CM/DCP will continue to conduct post discharge follow-up to ensure safe discharge.
- The SSD will report the number of discharges to different levels of care and report concerns as presented by residents or the responsible party on post discharge follow-up during quarterly QAA meetings. The QAA will monitor compliance and trends and provide recommendations during the meeting.