Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
A deficiency occurred when the facility failed to ensure a safe and appropriate discharge for a resident who used a wheelchair and required partial to maximal assistance with mobility and activities of daily living (ADLs). The resident, who had a history of stroke, falls, and moderate cognitive impairment, requested discharge to a room and board setting. The case manager (CM) referred the resident to a third-party agency for placement assistance and relied on the agency's verbal assurance that the placement was appropriate, without verifying the level of caregiver support or the suitability of the physical environment. The facility did not conduct or document its own assessment to determine if the discharge destination could meet the resident's needs, nor did it confirm with the receiving facility the availability of necessary caregiver services or accessible accommodations. Upon discharge, the resident was placed in a room and board facility that required residents to be ambulatory and independent. Contrary to what was communicated, the resident was assigned a bedroom on the second floor, which was inaccessible due to his wheelchair use. As a result, he had to sleep in a common area without privacy and lacked assistance for transfers and toileting. The bathroom was not wheelchair accessible, forcing the resident to use it with the door open. During his stay, the resident experienced multiple falls while attempting to transfer himself, and no documentation indicated that the facility followed up to ensure his safety or well-being after discharge. The room and board owner reported that the resident was not appropriate for their setting and could not be cared for safely. After several days, the resident was transported to a general acute care hospital due to recurrent falls, weakness, and lack of care. Hospital records confirmed the resident was not receiving necessary assistance and had frequent falls. The facility's own policy required individualized discharge planning, verification of the discharge setting's ability to meet the resident's needs, and documentation of discussions and follow-up, none of which were adequately performed in this case.