Failure to Ensure Safe and Appropriate Discharge Placement
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident with multiple complex medical conditions, including chronic gout, pneumonia, major depressive disorder, and acute kidney failure. The resident required assistance with activities of daily living (ADLs) such as transfers, toileting, bathing, and bed mobility, and was dependent on a wheelchair. Despite these needs, the facility discharged the resident to an unlicensed room and board setting without verifying that the environment could meet the resident's care requirements. The discharge documentation indicated the resident needed assistance with most ADLs, yet this information was not communicated to the receiving setting. Interviews revealed that the room and board manager did not assess the resident in person prior to admission and relied on a phone interview, during which the resident claimed to be independent. The facility's social services department did not follow up with the room and board manager after learning of the placement, and the third-party placement coordinator provided contact information but was unaware of the resident's care needs. The discharge packet sent to the third-party representative did not include documentation of the resident's functional or ADL status. As a result of these failures, the resident was confined to the kitchen area at the room and board facility, unable to access the restroom or maneuver stairs independently. The resident remained in this unsuitable environment for two days before being transferred to a general acute care hospital. Facility staff, including the Director of Nursing and Administrator, acknowledged that proper assessment and communication regarding the discharge location and the resident's needs did not occur.