Failure to Ensure Safe and Documented Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a resident's safe and orderly transfer or discharge. The resident, who had a complex medical history including dementia, schizoaffective disorder, morbid obesity, and multiple physical health conditions, was discharged following an incident involving bodily harm to another resident. Despite the resident's significant care needs and cognitive impairments, there was no evidence that the facility ensured the discharge destination could meet her needs or that the resident and her representative were adequately prepared for the transition. Record reviews revealed that the resident was discharged home with medications and some instructions, but without home health services or documented referrals for psychiatric observation. The discharge summary indicated that the resident's representative was unable to care for her due to work obligations and physical limitations, and the resident ultimately did not go to the representative's home but to another family member's residence. There was no documentation that the representative declined alternate placement, received ombudsman contact information, or was provided with a written or verbal notice of intent to leave the facility. Staff interviews confirmed that the discharge was not safe, as the representative could not properly care for the resident, who required 24-hour licensed nursing care. The facility's own discharge policy required assessment of the discharge destination's ability to meet the resident's needs, involvement of the resident or representative in planning, and documentation of referrals and responses. These steps were not followed or documented in this case. The lack of preparation and failure to ensure a safe discharge destination resulted in the resident being placed in an inappropriate setting, leading to further intervention by authorities and eventual transfer to a psychiatric hospital.