Failure to Ensure Safe and Documented Discharge Planning
Penalty
Summary
The facility failed to provide and document adequate preparation for a safe and orderly discharge for a resident, as well as failed to provide a comprehensive discharge summary that included a post-discharge plan of care and post-discharge services. Facility policy required that each resident have an individualized discharge plan developed by the interdisciplinary team, with input from the resident and their representative, to ensure a safe transition and that the discharge summary be furnished to the next care provider. However, review of the clinical record and staff interviews revealed that these requirements were not met for one resident. The resident in question had a history of atrial fibrillation, dementia with behavioral disturbance, repeated falls, and generalized muscle weakness. She was admitted after a fall that resulted in facial injuries and required 24-hour support due to her dementia. Throughout her stay, progress notes indicated ongoing confusion and a need for supervision and cueing. Although there were discussions about her care needs at home and plans to arrange for private home care assistance and home health services, there was no documentation that these services were actually set up prior to discharge. Additionally, the discharge summary lacked essential information such as the name and contact information for the home health agency and primary care physician, and did not document the resident's living arrangements post-discharge. Further, the discharge summary was incomplete in several sections, including dietary services, and failed to mention a significant unresponsive episode that occurred shortly before discharge. Interviews with facility leadership confirmed that there was no documentation of a review or assessment of the discharge plan to ensure all necessary measures were in place for the resident's safety. The facility was also without a social worker at the time, and social service responsibilities were being covered by other staff, which contributed to the lack of proper documentation and follow-through.