Failure to Ensure Safe and Orderly Discharge for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure safe and orderly discharge for a resident with significant medical and cognitive needs. The resident, who had diagnoses including anoxic brain damage, major depressive disorder, anxiety disorder, seizures, impaired mobility, severe malnutrition, and other chronic conditions, required supervision for all activities of daily living and medication management. Despite these needs, the facility discharged the resident to a homeless shelter without verifying that the shelter could meet his care requirements or that a bed was available. The shelter did not provide 24-hour medical staff, medication management, or guaranteed admission, and the resident was left standing in line without being checked in. There was no documentation in the resident's records of referrals for alternate placement, no evidence of a verbal or written notice of intent to leave the facility, and no documentation that the resident's representative refused to pick him up. The facility's social worker and administrator did not confirm the shelter's ability to provide necessary care or verify bed availability. The interdisciplinary team (IDT) did not consistently oversee the discharge decision, and there was inadequate documentation verifying safe placement and discharge readiness. The resident ultimately left the shelter, walked a significant distance, and was found by school security several days later, having apparently slept on the streets. Interviews with facility staff revealed a lack of communication and coordination regarding the discharge plan. The DON was unaware that the resident had not been discharged to his family as planned, and the administrator did not verify the shelter's services or admission process. The facility's discharge policy required IDT involvement, education, and documentation to ensure safe discharge, but these procedures were not followed in this case. The failure to provide and document sufficient preparation and orientation for discharge resulted in an unsafe situation for the resident.