Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who was sent to the hospital and subsequently discharged with paperwork indicating a return to a homeless shelter. The resident, who was cognitively intact and had a history of diabetes and traumatic brain injury, had expressed a desire to remain in long-term care according to their care plan. Despite this, the discharge paperwork listed a homeless shelter as the destination, and the discharge was marked as immediate due to the resident being considered a danger to self and others, with the notice lacking the resident's signature. Interviews with facility staff revealed a lack of clarity and documentation regarding the discharge process. The Social Services Director stated the resident did not request discharge, and the DON was unaware if the discharge packet was completed or if discharging to a homeless shelter was appropriate. The Administrator confirmed that the resident was told not to return to the facility and that the discharge was considered immediate, citing behavioral concerns such as inappropriate comments and alcohol use. However, there was no documentation of significant behavioral incidents in the medical record, aside from a single report of inappropriate comments. The facility was unable to provide a discharge policy when requested, and staff interviews indicated uncertainty about proper discharge procedures and documentation. The discharge notice was delivered to the hospital along with the resident's belongings, but the process lacked clear documentation and did not include the resident's agreement or signature. The actions taken did not align with the resident's expressed wishes or ensure a safe and appropriate discharge destination.