Failure to Arrange Ordered Home Health Services and Document Discharge Plan
Penalty
Summary
The facility failed to implement an effective discharge plan for a resident who was discharged home without the home health services ordered by the physician. The resident, who had diagnoses including generalized muscle weakness, difficulty walking, and unsteadiness on feet, required assistance with ambulation, transfers, toileting, dressing, bathing, and grooming. The discharge summary indicated the need for physical, occupational, and speech therapy at home, but did not provide information on how these services would be obtained. Additionally, the section of the discharge summary designated for the discharge planning or post-discharge care plan was left blank. Facility staff documented that no home health agency was available to provide services in the resident's area, and the resident's insurance did not have in-network agencies nearby. The social services assistant informed the responsible party that out-of-network services would be needed, but there was uncertainty about whether this was understood. As a result, the resident was discharged to the care of a family member without any home health services in place, despite being physically weak and unable to independently perform activities of daily living.