Failure to Ensure Safe and Documented Discharge Preparation
Penalty
Summary
The facility failed to ensure that a resident was adequately prepared for a safe and orderly discharge, and did not provide a complete discharge summary with a post-discharge plan of care. The resident, who had diagnoses including congestive heart failure and gastroesophageal reflux disease, was discharged home with physician orders for home health services, including physical therapy, occupational therapy, and skilled nursing. Multiple referrals to home health agencies were made, but all were unable to accept the resident prior to discharge. Despite this, the resident was discharged home without confirmation that home health services were in place, and there was no evidence that the physician was notified of the lack of services or that additional referrals were made at the time of discharge. The resident had an indwelling Foley catheter and was receiving oxygen at the facility, but the discharge summary did not mention the catheter, oxygen needs, or provide documentation of education on catheter management. There was also no instruction for follow-up with outside providers for catheter management or mention of the home health referrals in the discharge summary. The facility's policy required that residents and/or responsible parties receive teaching and discharge instructions, but there was no evidence that these requirements were met for this resident.