Failure to Ensure Safe and Informed Resident Discharge
Penalty
Summary
Facility staff failed to ensure that a resident's discharge needs were met, as evidenced by the lack of documentation that written discharge instructions were provided to the resident, failure to arrange home medications prior to discharge, and not supplying the resident with provider information that included standardized patient assessment data and quality measures for selecting a home health provider. The clinical record review showed that the resident was cognitively intact and was their own responsible party, with discharge planned to home with their spouse. Progress notes indicated ongoing discharge planning discussions with the resident and spouse, and referrals to home health and pharmacy were made, but there was no documentation of a discharge note or review of instructions and medications with the resident or family on the day of discharge. The discharge plan and instructions were electronically signed the day after discharge, and the nursing discharge summary was left blank. The social services discharge summary only briefly noted the discharge home and follow-up arrangements, but did not evidence that instructions were reviewed with the resident or family, nor that a copy was provided at discharge. Interviews with staff revealed inconsistent practices and uncertainty regarding the process for ensuring that prescriptions were signed and sent to the pharmacy prior to discharge, and that residents received their medications in a timely manner. Staff also indicated that while home health referrals were made, residents were not routinely given a selection of home health agencies or comparative data to make an informed choice, contrary to facility policy. Facility policy required that residents and their representatives be provided with information on post-acute care options, including quality and resource use data, and that all relevant discharge information be presented in an accessible format. However, the investigation found that this process was not followed for the resident in question. The lack of documentation and inconsistent staff practices led to a failure to ensure the resident was prepared for a safe discharge, with necessary instructions, medication arrangements, and provider choice information not properly provided or documented.