Failure to Ensure Safe Discharge with Required Equipment and Services
Penalty
Summary
A deficiency occurred when a resident, who was dependent on others for care and required a mechanical lift for transfers, was discharged home without the necessary equipment and services to meet her care needs. The resident had multiple diagnoses, including COPD with acute exacerbation, muscle weakness, schizophrenia, acute respiratory failure with hypoxia, chronic atrial fibrillation, hypertension, diabetes, and Parkinson's disease. The resident was cognitively intact but required total assistance for activities of daily living, including toileting, dressing, and transfers, and had an order for oxygen therapy. Prior to discharge, the care plan indicated the resident was at risk for self-performance deficits and was dependent for transfers, with no evidence of skin breakdown or pressure ulcers. On the day of discharge, the resident was sent home without oxygen, a working hospital bed, or a Hoyer lift, all of which were necessary for her care. The resident's husband was also ill and unable to provide assistance. The resident was left in a standard wheelchair for approximately six hours without any care, including incontinence care, resulting in the development of a pressure ulcer. EMS was called after the resident was found unable to care for herself, and she was transported to the hospital, where an open wound and saturated brief were noted. Hospital records confirmed the presence of a pressure ulcer and concerns about the lack of home care services and equipment. Interviews with facility staff and external care coordinators revealed that the facility did not coordinate with the resident's waiver service coordinator or home health services prior to discharge. The discharge was arranged by a social services designee who was no longer employed at the facility at the time of discharge, and the resident was discharged with only a standard wheelchair, as transportation could not accommodate her specialized chair. The facility's discharge policy required that discharge planning be based on the resident's needs and that all necessary resources be arranged, but this was not followed in this case, resulting in actual harm to the resident.