Failure to Plan and Document Safe Discharge With Confirmed Home Health and Supplies
Penalty
Summary
The deficiency involves the facility’s failure to document and plan the discharge process for one resident, resulting in a discharge that did not ensure needed services and supplies were in place. The resident was admitted with multiple serious diagnoses, including sepsis, osteomyelitis of the femur, COPD, muscle weakness, malignant neoplasm of the rectum, a colostomy, chronic kidney disease, and a female genital tract fistula, and had physician orders for daily wound care to a stage three pressure injury on the coccyx. Record review showed the resident’s care plan did not include a discharge plan, and progress notes lacked documentation of discharge planning discussions with the resident or the resident’s representative. A nursing progress note documented that the resident went home via stretcher, and a social service discharge note stated the resident was to receive home health, but there was no documentation of nursing discharge responsibilities, including education or supplies provided at discharge. Interviews and documentation further showed that the home health provider had not been confirmed prior to discharge, and no supplies were provided to the resident at the time of discharge. The resident’s representative reported the resident was discharged home without supplies and that the home health company did not show up. Social services later learned, through a post-discharge contact with the family, that the initial home health company had not agreed to care for the resident, and the resident had to obtain a different home health provider. Staff confirmed there was no documentation of the nurse’s role in the discharge and acknowledged that documentation should have included education and supplies given. Review of the facility’s Discharge Planning policy showed requirements for early discharge planning, completion of a discharge planning record, provision of discharge summaries and instructions, and post-discharge follow-up, which were not reflected in the resident’s record.
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