Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure safe and appropriate discharge planning for a resident by arranging a transfer to an assisted living facility without verifying that the receiving facility could meet the resident's needs and without confirming the accuracy of the discharge destination. The resident had complex medical conditions, including end-stage chronic kidney disease requiring dialysis, diabetes mellitus, dementia with fluctuating decision-making capacity, anxiety, and multiple healing fractures. The resident was dependent on nursing staff for activities of daily living such as toileting, showering, dressing, and transferring. Despite these needs, the facility initiated discharge orders to an assisted living facility without confirming the facility's ability to provide the necessary care or even verifying the correct facility name and location. Interviews and record reviews revealed that the receiving facility was not expecting the resident, was located in a different city, and typically only accepted independent, ambulatory residents without dementia. The Social Services Director was unable to locate the intended facility online and, upon contacting the administrator of the facility, discovered confusion regarding the resident's identity and admission. The discharge was ultimately delayed after it was determined that the transfer would not be safe or appropriate, and the discharge order was discontinued.