Failure to Arrange Home Health Therapy at Discharge
Penalty
Summary
The facility failed to ensure an appropriate discharge for one resident who required home health therapy services after being discharged following spinal fusion surgery. The resident, who had multiple diagnoses including spinal stenosis, diabetes, and scoliosis, was assessed as moderately cognitively impaired and required skilled therapy services for strength training and self-transfers. Discharge instructions indicated that the resident was to receive home health services for physical and occupational therapy upon returning home. However, there was no documentation that the facility initiated these services prior to discharge, and conflicting notes existed regarding whether the resident declined home health services. Staff interviews revealed uncertainty about whether home health was set up, and the social worker could not recall the details or confirm which agency was contacted. Further investigation showed that the resident did not receive home health services immediately upon discharge and only began receiving them after a follow-up appointment with a primary care provider, who then made the referral. The facility's discharge policy required the social service department to coordinate arrangements for home health services, but there was no evidence that this was completed as required. Additionally, there was no documentation that the physician or nurse practitioner was notified if the resident declined therapy services, nor was there evidence that Adult Protective Services was contacted to ensure the resident's safety, as per facility practice.