Failure to Ensure Safe and Orderly Discharge Planning
Penalty
Summary
The facility failed to provide an effective and safe discharge for a resident with complex medical needs, resulting in the resident being discharged to an unsafe home environment without adequate support or preparation. The facility did not follow its own discharge planning policy and procedure, as the interdisciplinary team (IDT) did not ensure that the discharge destination met the resident's health and safety needs or preferences. The care plan for discharge was not properly implemented, and the discharge summary lacked input and recommendations from the IDT, with sections left blank and signed off by a staff member who did not provide the required education or assessment. The resident had significant medical conditions, including Parkinson's disease, a recent above-knee amputation, diabetes, chronic kidney disease, and major depressive disorder. The resident required moderate assistance with activities of daily living, used a wheelchair, and had a non-weight bearing order on the left lower extremity. The resident's home environment was documented as cluttered, unsanitary, and lacking caregiver support, with the only available support being a power of attorney (POA) who lived an hour away and was not regularly present. Despite these factors, the facility discharged the resident home with only a home health agency referral, without confirming the adequacy of support or the safety of the environment. The discharge notice was not provided to the resident's representative or Ombudsman in a timely or understandable manner, and the POA was not included in discharge planning meetings. The facility staff did not coordinate with the IDT or verify the resident's home situation, and Adult Protective Services was not contacted despite the apparent risks. As a result, the resident was left alone at home for several days, was found on the floor with injuries, and required hospitalization. The facility's failure to follow its discharge planning process and ensure a safe transition led directly to the resident's harm.