Failure to Ensure Safe and Coordinated Discharge Planning for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and properly planned discharges in accordance with its own discharge planning policy. The policy required an IDT-driven discharge process, including a physician’s order, coordinated discharge planning by social work, therapy home assessments as needed, referrals to home health or other services, nursing education on medications and treatments, and completion and distribution of a discharge summary with documentation in the medical record. Surveyors found that these steps were not followed or documented for two residents who were discharged. For one resident with anxiety, diabetes, and open-angle glaucoma, there was no baseline care plan in the record and the resident reported being “kicked out.” The social worker reportedly told the resident it was not in her job description to find a new placement and stated she could not help residents file appeals. The resident received a NOMNC with a set discharge date and reported being unable to fully participate in therapy due to COVID and a strained neck. Therapy staff, including the OT and the Director of PT/OT, described the resident as non-ambulatory, needing moderate assistance with showering, assistance with toileting and dressing, and having very weak legs. The Director of PT/OT stated she did not feel it was safe for the resident to return home due to the number of stairs and the resident’s limited ability to manage steps, yet the resident was discharged home after arranging their own transportation, with no indication of a coordinated safe discharge plan. For another resident who was cognitively intact and had multiple diagnoses including hypertension, peripheral vascular disease, diabetes, hyperlipidemia, depression, and asthma, the record contained no physician order for discharge. The only documentation was a progress note stating the resident was discharged home with medications and that nurse management was aware. There was no documentation of discharge planning, referrals, outside resources, or a discharge summary in the medical record. In an interview, the DON stated that the expectation was for the social worker to assist with discharge planning and for all services to be documented, including a discharge summary, but this was not done for the residents reviewed.
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