Unsafe Discharge Without Adequate Planning or Aftercare
Penalty
Summary
A resident with multiple complex medical conditions, including a recent abdominal surgery with wound dehiscence, end-stage renal disease requiring hemodialysis, and significant mobility and self-care needs, was discharged from the facility when Medicare coverage ended. The facility was aware that the resident's family could not provide adequate care at home, as they lived in an RV that was not accessible for a wheelchair and lacked the necessary resources. Despite this, the facility proceeded with the discharge without ensuring an appropriate discharge plan, transfer documentation, or aftercare arrangements. The resident's care plan had called for coordination with community resources and continued therapies, but these interventions were not implemented. Physician orders for continued physical therapy, occupational therapy, and registered nursing services were not followed at discharge. The discharge instructions were incomplete, lacking scheduled follow-up appointments, special instructions for wound care, and signatures from the resident or family. The wound VAC device, which was facility-owned, was removed prior to discharge, and no replacement was arranged, leaving the resident with an unattached wound dressing. The facility did not communicate with the receiving hospital or provide necessary transfer documentation, despite being informed by the family that the resident would be taken directly to an acute care hospital after discharge. Upon arrival at the hospital, the resident was found with a malfunctioning wound VAC and an open abdominal wound, requiring immediate surgical intervention. Interviews with facility staff, including the Social Services Director, Administrator, Operations Manager, and Director of Nursing, revealed that discharge planning was inadequate and that critical steps, such as arranging aftercare and communicating with the receiving facility, were missed. The facility's own policies required that transfers and discharges be based on the resident's needs and preferences, and that appropriate documentation and communication occur, but these were not followed in this case.