Discharge Plan Not Updated After Home Health Services Declined
Penalty
Summary
The facility failed to update a resident's discharge plan to accurately reflect the status of home health services following a referral for wound care. The resident, who had a right below knee amputation (BKA) and required ongoing wound care, was discharged home with the expectation that home health wound care services would be provided. Although the facility initially contacted a home health agency to arrange for these services, they were notified prior to discharge that the agency would not be able to provide care. Despite this, the discharge summary and instructions given to the resident indicated that home health services were set up and that wound care would be provided on specific days. Interviews with facility staff, the resident, and the complainant confirmed that the resident was discharged with a wound vac machine and instructions to contact home health if issues arose, but no actual wound care arrangements were in place at the time of discharge. The Social Services Director acknowledged awareness that home health services had been declined prior to discharge, and the Medical Director confirmed that the discharge instructions should have been revised to reflect the lack of home health services. The resident was educated on the risks of being discharged without these services but still preferred to go home. The facility did not update the discharge plan to accurately reflect the absence of home health wound care arrangements.