Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to ensure safe discharge planning for two residents. One resident, admitted with cellulitis, was discharged home with recommendations for 24-hour care and home health services. However, the facility did not confirm with the resident's identified friend whether assistance would be available, nor did they notify the friend prior to discharge. The resident was discharged without verification of home conditions or provision of resources for in-home caregivers. Upon arrival home, the resident encountered unsafe living conditions, including the presence of rats and lack of running water, and had to seek shelter with a neighbor before being transported to the hospital for further discharge planning. Staff interviews revealed that the facility did not provide the resident with information about the risks of discharging without 24-hour caregivers, did not supply a list of local resources, and did not confirm the availability of the friend to assist post-discharge. Another resident, admitted with a fracture and cognitively intact, was discharged with instructions that included post-discharge appointments. However, the discharge paperwork did not include an updated appointment that was scheduled during a post-operative visit on the same day the discharge instructions were printed. As a result, the resident and family missed an important follow-up appointment. Staff acknowledged that the most current appointment information was not transcribed onto the discharge instruction sheet, leading to incomplete discharge instructions.