Failure to Provide Proper Discharge Planning and Ombudsman Notification
Penalty
Summary
The facility failed to provide a proper discharge for a resident, as evidenced by the lack of a discharge plan, discharge summary, and appropriate physician orders for discharge. The resident, who had diagnoses including orthostatic hypotension, diabetes mellitus, dehydration, dysphagia, and anxiety disorder, was cognitively intact but dependent on staff for medication administration and required assistance with activities of daily living. Despite the resident expressing discomfort and uncertainty about self-administering insulin and not feeling ready to go home, the discharge proceeded without ensuring a primary care physician was in place or a follow-up appointment scheduled. The discharge documentation was incomplete, with only the social services section partially filled out and no signatures or summaries from nursing, dietary, activities, or rehabilitation services. The resident was discharged to an independent living apartment, not an assisted living facility as some staff believed. Upon discharge, the resident did not have insulin or a primary care physician, and home health staff had to intervene to secure necessary medication and assist in finding a physician. The facility's own policy required a discharge summary and post-discharge plan to be developed and filed in the resident's medical record, but this was not done. Interviews with staff confirmed the absence of a discharge summary, discharge plan, and proper coordination for the resident's ongoing care needs. Additionally, the facility failed to properly notify the local ombudsman office of the resident's discharge. Monthly discharge lists were faxed to an incorrect number, and there was no documented evidence that the ombudsman received any notifications of discharges over a six-month period. The ombudsman confirmed they had not received any such notifications, and the facility administrator acknowledged the error and lack of documentation.