Failure to Ensure Proper Discharge Process and Documentation
Penalty
Summary
The facility failed to ensure the proper process of discharge for a resident, as evidenced by a lack of required documentation and communication regarding the resident's needs, appeal rights, and bed-hold policies. The assigned Social Services Coordinator was repeatedly unresponsive to the family's attempts to communicate and did not follow through on discharge planning. During the Social Services Coordinator's leave of absence, the resident was unable to obtain a necessary RN assessment for home care setup. Upon the coordinator's return, the RN assessment was completed, but the family was then informed of difficulties obtaining insurance clearance for home care. There was no documentation provided regarding the expiration and renewal of the resident's Medicaid benefits, nor was there evidence of communication or transfer of responsibility to another social worker during the coordinator's absence. The resident, who had developed a wound during their stay, left the facility on an approved leave of absence with family and subsequently declined to return. The facility discharged the resident due to failure to return, but no home care was arranged, and the required discharge documentation was not provided. The wound worsened and became infected, resulting in the resident's hospital admission. Record reviews and interviews confirmed the absence of documentation related to discharge readiness, home care approval, and communication with the family, indicating a failure to follow the required discharge process.