Failure to Ensure Safe and Coordinated Discharge Planning and Medication Provision
Penalty
Summary
The deficiency involves the facility’s failure to execute an orderly and effective discharge for one cognitively intact resident who was discharged home. Facility policy on transfer or discharge required that information such as disposition of medications and confirmation that receiving providers’ services were available to meet the resident’s needs be communicated at discharge. The resident had multiple diagnoses, including aphasia following cerebral infarction, type 2 diabetes with neuropathy, unspecified dementia, depression, duodenal ulcer, and fibromyalgia, but was assessed as cognitively intact with no behavioral issues and needing only minimal to moderate assistance with activities of daily living. At discharge, the facility’s discharge summary identified the resident’s pharmacy of record and stated that prescriptions were conveyed to the pharmacy by fax, but the pharmacy fax number line was left blank. Review of pharmacy records showed that discharge medication orders were not actually transmitted to the pharmacy until seven days after discharge, and there was no evidence that prescriptions were sent at the time of discharge as documented. The DON later confirmed the facility could not provide any information showing that prescriptions were faxed on the discharge date and that the electronic transfer of prescriptions occurred a week later, after a family complaint. The facility also failed to ensure appropriate post-discharge services and follow-up medical care were arranged. The resident was referred to a local home health agency for PT, OT, and nursing services, but the agency was out of network for the resident’s insurance and therefore did not admit the resident. The home health service director reported notifying the facility on the day of referral that the resident was not eligible, but the facility did not return the call or make an alternative in-network referral. The SSD, who coordinated the discharge, did not schedule a follow-up appointment with the resident’s primary care physician, stating the resident said she would do it herself, and was unaware that the home health provider was out of network. The DON and Administrator confirmed that multiple staff responsible for discharge planning and care coordination were off duty over the holidays, no backup personnel were designated, and messages from the home health provider were not relayed, resulting in a failure to provide a safe and effective discharge plan for the resident’s wound care, therapy, and medication needs.
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