Failure to Provide Discharge Instructions and Supplemental Oxygen at Discharge
Penalty
Summary
The facility failed to provide a discharge summary and supplemental oxygen at the time of discharge for one resident. Facility policy titled "Discharge Summary and Plan" required that, when discharge was anticipated, a discharge summary and post-discharge plan be developed and that a copy of the evaluation of discharge needs, the post-discharge plan, and the discharge summary be provided to the resident and receiving facility, with a copy filed in the medical record. The resident, who had a medical history including respiratory failure, was admitted on 11/07/2025 and discharged home with home health services on 11/27/2025. The resident’s responsible party reported notifying the Admissions Coordinator the day before discharge that the resident would be going home and was told discharge paperwork would be ready at pickup. When the responsible party arrived to take the resident home, the facility did not have the discharge paperwork available, and although a nurse attempted to contact someone to obtain it, they were unsuccessful. The responsible party left the facility with the resident without any discharge paperwork. The resident had been receiving supplemental oxygen while in the facility, but the responsible party stated the resident was discharged without supplemental oxygen. The Social Worker reported that her usual process at discharge was to set up home health, print durable medical equipment orders, and provide discharge paperwork at the time of discharge, but she was not working during the resident’s holiday-weekend discharge. She believed the discharge paperwork was mailed and confirmed that on 12/01/2025 she reviewed the discharge paperwork with the responsible party by phone, four days after discharge. The Social Worker stated that if a resident received supplemental oxygen in the facility, they would be discharged with an order for supplemental oxygen, and confirmed that this resident had received supplemental oxygen in the facility but had no orders for supplemental oxygen at discharge. Review of the Discharge Instruction Form showed it was signed by the Social Worker and dated 12/01/2025, with a handwritten note indicating the instructions were discussed verbally with the responsible party on that date. The DON and Administrator both stated their expectation that residents receive education, medications, post-discharge arrangements, and discharge paperwork at the time of discharge.
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