Failure to Ensure Safe Discharge Preparation and Caregiver Training
Penalty
Summary
The facility failed to ensure adequate preparation and orientation for a safe and orderly discharge of a resident who required enteral feeding and assistance with transfers. Specifically, the facility did not arrange for the resident's enteral feeding formula to be readily available upon discharge, providing only a one- to two-day supply and leaving the caregiver to obtain additional formula independently. Additionally, the facility did not assess or verify the caregiver's ability to safely transfer and care for the resident, nor did it provide training or instruction on safe transfer techniques. The resident's caregiver reported not being aware of the resident's inability to get out of bed without assistance and did not receive training or incontinence supplies upon discharge. Interviews with facility staff confirmed that there was no assessment of the caregiver's competence in transferring the resident, and discharge instructions did not include necessary training or arrangements for ongoing care needs. The facility's policy required orientation and documentation to ensure safe discharge, but this was not followed in this case. The resident had a history of cerebral infarction, traumatic brain disorder, and required assistance with activities of daily living, making these omissions significant in the context of the resident's care needs.