Failure to Arrange Home Health and Community Referrals at Discharge
Penalty
Summary
Facility staff failed to ensure that home health services and community referrals were in place at the time of discharge for a resident who was transitioning to an independent living apartment. The resident, who had been admitted for rehabilitation following hospitalization and was later determined not to require skilled nursing services or meet the criteria for nursing facility level of care, was discharged without the necessary referrals for home health and meals on wheels. The referrals were not made until three days after discharge. Interviews revealed that the staff member responsible for the discharge was inexperienced with independent living discharges and was unaware of the resources needed for the resident. The regional social worker became involved after the fact and directed the necessary referrals, which resulted in a delay in the resident receiving home health services. The Director of Nursing confirmed that the facility did not have the required services and referrals in place at the time of discharge.