Failure to Ensure Safe and Appropriate Discharge Placement
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident by not following the physician's order and the resident's stated preference for discharge to a Board and Care facility. The resident, who had diagnoses including hypertension, glaucoma, lack of coordination, and protein-calorie malnutrition, required supervision or assistance with activities of daily living such as bathing, dressing, transferring, and toileting. The care plan and physician's order specified discharge to a Board and Care with home health services for physical and occupational therapy, as well as nursing support for medication compliance. However, the resident was instead discharged to a recuperative care facility, which is intended for individuals recovering from illness and experiencing homelessness, and does not provide the level of care or services required by the resident. Interviews and record reviews revealed that there was miscommunication between the facility's social worker, the Director of Patient Care, and other staff regarding the discharge destination. The Director of Patient Care and the case manager both confirmed that the resident was discharged to a recuperative care facility rather than a Board and Care, and that the facility did not verify whether the placement met the resident's needs or was safe. The resident expressed discomfort and fear upon arrival at the recuperative care facility, noting concerns about safety and the environment, and subsequently left the facility on his own. The facility's own policy required that discharges meet specific criteria, including resident notification, orientation, and documentation. The Director of Nursing and the administrator acknowledged that the discharge did not follow the physician's order or the resident's preference, and that the facility failed to screen the discharge location to ensure it was appropriate and safe for the resident. This resulted in an inappropriate discharge that did not meet the resident's needs or preferences.