Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was homeless and required ongoing care for multiple burn wounds. The resident, admitted with third-degree burns covering 20-29% of her body, muscle wasting, mobility disorders, and MRSA carrier status, was discharged without proper arrangements for home health nursing services, food, or transportation to follow-up medical appointments. The case manager/social worker did not contact homeless shelters or home health agencies, nor did she provide the resident with written discharge instructions or information for follow-up care. The resident was only verbally informed of her discharge the day before and was not advised of her right to appeal the discharge. The discharge plan was not individualized or reviewed with the resident, and the facility did not ensure that the resident's needs and preferences were met. The administrator attempted to secure a motel room for three nights but did not make a reservation or arrange for food, nursing care, or a long-term shelter solution. There was no documentation of a discharge plan or communication with the resident regarding the plan. The facility's own policy required a discharge summary and plan to be developed and reviewed with the resident and family at least 24 hours before discharge, but this was not followed. Interviews with facility staff, including the DON and wound nurse, revealed a lack of awareness and preparation for the resident's discharge needs. The wound nurse acknowledged that the resident would not be able to care for wounds on her back and had not provided any education or training for wound care. The facility's failure to coordinate post-discharge care, secure appropriate shelter, and provide necessary information and resources resulted in a discharge process that did not address the resident's health and safety needs.