Failure to Ensure Safe Discharge and Continuity of Care for Resident with Diabetes
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with diabetes and diabetic wounds, resulting in Immediate Jeopardy. The resident, who was homeless and had no identification, was discharged to the Department of Social Services via family transportation without prior consultation with the Department to confirm the availability of housing or supportive services. The discharge planning process did not include verification that the resident's health and safety needs or preferences were met, and there was no evidence that the resident or their representative received or signed discharge instructions. The resident was discharged without proper education or supplies to manage their diabetes and diabetic wounds. Documentation was lacking regarding the provision of insulin, a glucometer, or wound care supplies, and there was no record of medication reconciliation or teaching for diabetes management. Interviews with facility staff revealed confusion about responsibilities for discharge education and supply provision, and it was confirmed that the resident did not have a primary care provider established at the time of discharge, which prevented the setup of home health or wound care services. After discharge, the resident was denied emergency housing at the Department of Social Services due to a previous unpaid stay and had to rely on their sibling for temporary accommodation and basic needs such as food. The resident subsequently presented to the emergency department with dangerously high blood sugar, having been discharged from the facility without insulin or medications sent to a pharmacy. Interviews with staff and the resident's family confirmed that the resident was not adequately prepared or equipped for self-care post-discharge, and that the facility's discharge process failed to ensure continuity of care or resident safety.
Removal Plan
- The pending discharge was reviewed for verification of post-discharge services, receiving locations, and physician notification.
- Social Services, the Nursing Management team involved in discharges, Director and Assistant Director of Rehabilitation, and the Recreation Director were educated on discharge planning process to include verification of safety and discharge medication.
- A new discharge form was instituted that required medication listed with quantities, medical equipment provided, teaching provided, and discharge location that required both resident/resident representative signature in addition to discharging nurse.
- All discharges in the last 30 days were reviewed for safety and called to ensure they had the necessary services in place.
- All staff identified for education received education, with the exception of staff members who were not available. The individuals who did not receive education will complete education upon their return, prior to the start of their shift.
- Interviews were completed to determine compliance with staff training and education including the Director of Social Services, the Recreation Director, the Assistant Director of Rehabilitation, one Unit Manager, and the Director of Nursing.