Failure to Prepare and Document Safe Discharge for Resident
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident who was issued a 30-day discharge notice due to non-compliance with the facility's smoking policy. The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, and demonstrated moderate cognitive impairment, was identified as needing set-up assistance with personal hygiene and supervision with transfers and ambulation. Despite care plan interventions directing the social worker to utilize community resources, prepare the resident for discharge, and involve the resident in discharge planning, there was no evidence that these steps were taken. The social worker admitted to not having made additional discharge plans or discussed future arrangements with the resident after the initial notice was given. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge. The DON was unaware of the discharge details and the resident's status was not included in daily meetings or on the facility's tracking board. The administrator was also unaware of the discharge notice and its reason. The MDS coordinator noted unresolved insurance issues and did not follow up further, while the admissions coordinator at the sister facility had not received a referral. Nineteen days after the notice, the social worker still had not arranged for a safe discharge, and the resident reported not receiving any further information about the transfer after the initial notice.