Failure to Implement Effective Discharge Planning Leading to Post-Discharge Instability
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident with multiple cognitive and physical impairments. The resident was admitted with diagnoses including cognitive communication deficit, a history of traumatic brain injury, ataxia, and repeated falls, and had a BIMS score of 12 indicating moderate cognitive impairment. The facility’s own policy required that discharge planning begin upon admission, with an initial discharge assessment within seven days and a discharge care plan developed by Social Services with the IDT. However, the Director of Nursing confirmed that the clinical record contained no evidence of discharge planning prior to the actual discharge date and no discharge care plan was developed. An IDT note documented that a family member had contacted the facility about discharge plans and was working on financial benefits, but there was no further documentation of coordination or follow-up with the family member regarding these plans. On the day of discharge, the resident was sent in an Uber to an assisted living facility with medications and a medication list documented as provided to the subsequent provider, but not to the resident. The Discharge Planning Review Form was completed and signed the day after discharge and lacked the resident’s or family member’s signature. Following discharge, a home health RN reported that when she assessed the resident for home health admission, the resident did not have a medication list or discharge medications, requiring the home health office to contact the facility for this information. Staff at the assisted living reported that the resident claimed to self-administer medications but did not show which medications, ambulated without a walker in an unusual manner, and frequently wandered off to an unknown shelter. The assisted living owner reported that the resident occasionally left the home, sometimes becoming dirty after being homeless for a few days, and that although the resident received financial benefits, they did not know who the payee was or who was receiving the money.
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