Failure to Safely Coordinate and Document Bariatric Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to safely discharge a resident with significant medical and equipment needs. The resident had diagnoses including diabetes and bipolar disorder, no documented cognitive impairment, and a recorded weight of 426 lbs, requiring bariatric equipment. The face sheet listed the discharge destination only as an unknown nursing home, and the facility assessment and records did not clearly document the receiving facility. The social services staff member reported that the resident was transferred approximately 145 miles away to a nursing home that accepted bariatric residents, but she did not verify the resident’s status after transfer, could not recall whom she spoke with at the receiving facility, and did not document this communication in the medical record. The administrator of the intended receiving nursing home stated that the resident was never admitted there. The resident and a family member reported that upon arrival at the intended nursing home, the facility did not have a bariatric bed or bariatric wheelchair available, and the resident became anxious with palpitations and was sent to the ER. The hospital then arranged placement at a different nursing home that had the needed equipment. The LPN who discharged the resident stated she sent only the resident’s discharge medications and did not provide any additional discharge papers because she was not instructed to do so. The DON stated that discharge to another nursing home should include written discharge instructions such as a medication list, equipment needs, and a copy retained in the medical record to ensure continuity of care and safety. The facility’s own policy on notice of transfer and discharge required documentation of the transfer in the medical record, communication of appropriate information to the receiving institution, and review of necessary items including DME, prescriptions, appointments, and treatments, which was not followed in this case.
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