F0745

D

Failure to Provide Adequate Social Services for Safe Discharge of Cognitively Impaired Resident

Ephrata, Pennsylvania Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate medically-related social services to ensure a safe discharge home for a resident with significant cognitive impairment. The resident had diagnoses including altered mental status and metabolic encephalopathy, and admission physician orders documented that the resident was not capable of understanding and exercising their own rights. Nursing notes over several days described frequent confusion and disorientation, including the resident being found in the hallway with a purse, not knowing where their room was. A nurse practitioner’s assessment documented dementia associated with alcoholism, orientation only to self, a SLUMS score of 16/30 indicating a marked severe level of impairment, tangential thought processes, and a determination that the resident was not capable of making sound medical decisions.

The NP’s note also documented concern about the discharge plan because the resident lived alone in a dilapidated trailer with unsanitary living conditions and had limited support from an ex-husband who was minimally involved. Social services notes showed that when discharge planning was discussed, the resident gave inconsistent information about their living situation, alternately describing a two-story home and a manufactured home, and reporting involvement of an ex-husband and an ex-boyfriend. The social worker reported that the ex-husband expressed concerns about the home, including holes and soft spots in the floor, but also confirmed that neither the resident’s description nor the ex-husband’s report of the home environment was verified by the facility. The rehab director stated that the resident was physically cleared but had cognitive impairment making them unsafe to go home, and acknowledged that no home check was performed despite conflicting information about the residence.

Despite documented concerns about the resident’s mental status, decision-making capacity, and the safety and cleanliness of the home environment, the resident was ultimately discharged home with an order stating they were stable for discharge with support services. Nursing documentation indicated that the resident was discharged home accompanied by the ex-husband, even though the facility was aware of the resident’s impaired mental status and safety concerns at the mobile home. Social services contacted the Office of Aging to report an unsafe discharge and provided information about the home conditions and the resident’s increased confusion, but there was no follow-up by social services after the resident’s discharge. A licensed social services employee later reported only hearing from the hospital that the resident had been sent back a few days after discharge. These actions and omissions led to the determination that the facility failed to ensure the resident received all necessary social services to support a safe discharge home.