F0627

D

Failure to Document and Coordinate Safe Discharge Planning and Home Health Referrals

Waukesha, Wisconsin Survey Completed on 02-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that discharge planning for one cognitively intact resident included documented coordination of services, resident participation, and verification of a safe and appropriate transition to the community. The facility’s own Discharge Planning policy requires timely documentation of discharge needs and plans, discussion of the evaluation results with the resident or representative, and development of a post-discharge plan of care indicating the discharge location and arrangements for follow-up care and services. For this resident, the medical record did not contain a completed discharge summary, documentation of a care conference discharge meeting, or confirmation that post-discharge needs and services were fully addressed prior to discharge. The only progress note related to discharge indicated that the resident was discharged home with paperwork and medications, that van transport arrived, and that a family member was waiting at the destination.

The resident was admitted with respiratory failure, cognitive communication deficit, heart failure, and muscle weakness, and had significant functional limitations requiring substantial/maximal assistance with transfers and dependence for walking at admission. At discharge, the MDS showed the resident remained cognitively intact with a BIMS score of 13, required partial/moderate assistance for sit-to-stand and bed-to-chair transfers, and was not assessed for car transfer or walking 10 feet due to medical or safety concerns. The care plan documented that the resident wished to discharge home or to the community, with interventions to evaluate the resident’s motivation and ability to safely return to the community and to identify gaps in abilities affecting discharge. However, there was no documentation that these evaluations and care plan interventions were completed or that discharge goals were met before the resident left the facility.

Interviews with staff revealed that the social worker managed discharge planning and home health referrals but did not document care conferences or discharge planning discussions in the medical record, instead keeping and then deleting personal notes. The LPN reported that nursing’s role in discharge was limited to belongings and medication management, that a paper discharge checklist was used but not part of the medical record, and that the discharge was “fast and abrupt” once insurance ended. The OT stated that therapy determined the resident was not appropriate to live alone at discharge, recommended home health services, and communicated these recommendations to the social worker, but the medical record contained no documentation that home health referrals were initiated, completed, or formally declined by the resident. The social worker reported that a phone conversation with the resident’s brother led to not sending the home health referral, based on the brother’s reluctance to have services in the home and his statement that family would assist, but this was not documented, and the facility did not verify this information with the resident, who was his own decision maker. There was no documentation confirming the adequacy of caregiver support or the safety of the discharge environment, and leadership acknowledged that the expected discharge summary, care conference documentation, and follow-through on therapy referrals were not present in the record.