F0627

D

Failure to Ensure DME Delivery Prior to Discharge for Dependent Resident Living Alone

Manassas, Virginia Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure that all discharge needs were met for a resident who was discharged home without confirmed delivery of essential durable medical equipment (DME), specifically a bedside commode, despite the resident’s inability to negotiate stairs and the bathroom being located on the second floor of a multi-level home. The resident’s admission MDS documented partial/moderate assistance needs for bathing, upper body dressing, and standing from sitting, and substantial/maximal assistance for toileting and lower body dressing. Toilet transfers and walking were not attempted due to medical or safety concerns, and the resident was frequently incontinent of bowel and bladder, had frequent severe pain, and had a recent fall and major surgery prior to admission. The social services admission assessment identified significant barriers to a safe discharge, including that the resident lived alone, had 13 steps to reach the bathroom level, had no supervision, and no family supports, and it documented that social services would arrange home health and any needed equipment at discharge.

A safe transition meeting documented that the resident’s goal was to return home alone and again identified barriers such as living alone and the 13 steps to the second-floor bathroom. Therapy discharge documentation later specified that the resident required supervision or touching assistance for toilet transfers and recommended home health services and multiple environmental and equipment modifications, including an elevated toilet seat/3-in-1 commode, shower bench, grab bars, assistance with ADLs, and a Lifeline for safety. PT documentation indicated the resident required supervision for all bed mobility and transfers and remained non–weight bearing on the right leg, unable to go up or down stairs at discharge. Progress notes showed that the resident repeatedly appealed Medicare non-coverage decisions, stating they were not ready for discharge, were unable to put weight on one leg, and that the other leg had become weak, but the appeals were ultimately denied and liability began prior to discharge.

On the day before discharge, a late-entry social services note documented that the writer attempted to order oxygen and a bedside commode due to the resident’s bathroom being on the second floor and the resident’s inability to walk or climb stairs, and that the resident did not qualify for oxygen. A nurse practitioner note on the day of discharge stated the resident was in stable condition for discharge home with home health and skilled nursing, and referenced coordinating DME with social work. The facility’s internal DME chat log showed the social worker created the order for a 3-in-1 bedside commode in the late afternoon the day before discharge, with the DME provider accepting the order that evening and marking it pending further review. The DME company attempted to contact the resident around midday on the day of discharge and later documented awaiting a callback to discuss financial obligation and delivery, with the order ultimately canceled nearly two months later. A faxed email chain from the home health agency showed that staff were unable to reach the resident on the day of discharge and subsequent attempts, and later documented that when they finally spoke with the resident several days after discharge, the resident reported having fallen at home on the day of discharge and going to the emergency room, then refusing return to the original facility and being admitted to another facility. Interviews with the social services assistant and rehab director confirmed that therapy had recommended a bedside commode, that social services was responsible for arranging DME, that the resident was non–weight bearing and unable to manage stairs at discharge, and that there was no evidence the bedside commode had been delivered to the home prior to discharge.