Failure to Ensure Safe and Appropriate Discharge for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident with complex medical needs, including sepsis, encephalopathy, Parkinson's disease, a stage 4 sacral pressure wound, and adult failure to thrive. The resident was non-verbal, required significant assistance with activities of daily living, and was dependent for toileting and lower-body dressing. Despite documentation from the primary care provider and facility staff indicating that the resident required a higher level of care and that discharge home would be unsafe, the resident was discharged home without adequate supports in place. Discharge planning was insufficient, as the resident's daughter, who did not have legal authority to act on her behalf, signed the discharge paperwork. There was no documentation that the resident participated in or consented to the discharge decision. The facility did not arrange for home health or wound-care services, and necessary equipment such as a low-pressure mattress was not provided. The resident's significant other, identified as the primary caregiver, did not receive training or instruction regarding the resident's care needs, and staff expressed doubt about his ability to provide the required level of care. Following discharge, the resident was found at home without appropriate care, experiencing pain and complications from the existing stage 4 wound, which led to hospitalization. The facility staff, including nursing and the physician, believed the discharge was unsafe, and there was no evidence that guardianship or Medicaid application processes were pursued to ensure the resident's needs were met. The discharge was documented as against medical advice, but the facility did not fulfill its responsibility to ensure a safe and coordinated transition, resulting in harm to the resident.