Failure to Complete and Implement Effective Discharge Planning for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge planning process for two residents who were discharged to an independent living facility (ILF). Resident 2, admitted with cognitive communication deficit, depression, and stage 3 chronic kidney disease, was discharged without assistance in obtaining a government ID and debit card that were known to be missing. The Social Services Director acknowledged that Resident 2 did not have these items and that she did not assist him in acquiring them before discharge, despite knowing he needed them to pay rent at the ILF. The Social Service Note documented that discharge instructions, including follow-up appointments and a medication plan, were reviewed, but there was no evidence that the facility ensured Resident 2 had the financial and identification resources necessary for his planned living arrangement. Record review for Resident 2 showed a physician’s order for home health services and a primary care physician appointment after discharge, but the Discharge Summary and Post-Care Instructions form had blank fields for the primary care physician’s name, appointment details, phone number, address, and pharmacy information. A copy of this incomplete document was given to the resident at discharge. The Independent Living Facility owner reported being unaware that Resident 2 lacked an ID or debit card and stated that the resident left the ILF and did not return. The home health RN reported that Resident 2 did not have a medication list at the ILF and that there was no established pharmacy or primary care physician. The case manager confirmed that the medical record lacked documentation of a pharmacy for medication pick-up, did not indicate that a primary care physician was established, and contained no discharge planning documentation until the day of discharge. For Resident 3, who had diagnoses including myopathy, COPD, epilepsy, anxiety disorder, and spinal stenosis, the discharge documentation was also incomplete. The Discharge Summary recorded the discharge date but did not include the discharge location or transportation method, although the Social Services Director later stated that the resident was discharged to an ILF. The Discharge Summary and Post-Care Instructions for Resident 3 similarly had incomplete information in the Post-Discharge Plan of Care Services, Referrals, and Equipment section, with blank fields for primary care physician name and appointment details, phone number, address, and pharmacy information, even though a copy was provided to the resident at discharge. Review of the facility’s policy on Discharge Summary and Plan showed that staff were required to assist in finding a primary care provider if the resident had none and to document their efforts, but the records for both residents lacked this documentation and complete discharge planning details.
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