Failure to Provide Adequate Discharge Instructions and Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide specific discharge instructions and necessary documentation regarding a resident's cognitive status, medication administration, and food preparation needs to the home health provider at the time of discharge. The resident in question had multiple diagnoses, including dementia with psychotic and mood disturbance, memory deficit, speech and language deficits, dysphagia, and severe cognitive impairment. Despite these conditions, the discharge process did not include comprehensive communication of the resident's needs to the home health agency, nor did it ensure that the resident had adequate support or supervision at home. The clinical record and interviews revealed that the resident was discharged home alone, with no verified support network or caregiver present. Discharge education and instructions were provided only to the resident, despite her severe cognitive impairment and inability to manage her medications independently. The home health agency did not receive a complete discharge summary, medication list, or therapy notes, and was not notified of the urgency of the resident's needs. The resident was not assessed for her ability to manage medications or recall instructions, and there was no verification of food availability or environmental safety in her home. Upon the home health agency's initial visit several days after discharge, the resident was found to be confused, isolated, and unable to care for herself, with poor hygiene, nutrition, and mobility. She was not taking her medications and had no support network available. The lack of communication and coordination between the facility and the home health provider, as well as the failure to ensure the resident's needs were met upon discharge, directly contributed to the deficiency cited in the report.