Failure to Ensure Safe Discharge Planning and Transportation for a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe discharge plan for a resident whose needs and preferences required more support than was arranged. The resident was admitted after hospitalization and was initially documented as alert and oriented on the 5-day MDS. Subsequent EHR entries showed that the provider did not recommend discharge home alone due to safety concerns. Therapy and nursing documentation indicated the resident required maximum assistance with dressing, was dependent with toileting, refused to work on bed mobility, transfers, and ambulation, and demonstrated poor safety awareness. The resident’s cognition was documented as impaired: she was unable to sign the NOMNC due to decreased cognition, had a BIMS score of 9 indicating moderately impaired cognition, and scored 9/20 on a verbal test of practical judgment, suggesting severe impairment in judgment skills. Despite these findings, the facility planned to discharge the resident home and proceeded with discharge. The resident’s son expressed concerns to social services about the cleanliness of the home, the likelihood that the resident would not take medications as prescribed, and reported that informal supports would no longer assist due to safety concerns about her being home alone. The EHR documented that the resident was discharged against medical advice, with the discharge described as being facilitated to promote a safe environment at home. When the resident’s arranged ride did not arrive, transportation support staff provided transport to the home at the request of social services. The social services assistant later stated she did not feel the resident should have been discharged home but was unsure of what options were available, and the administrator reported being unaware that facility transportation had been provided for this discharge.
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