Failure to Ensure Safe, Coordinated Discharge and Representative Involvement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident with multiple serious medical conditions. The resident was admitted with diagnoses including heart failure, palliative care needs, unspecified dementia, and COPD. An MDS dated 5/15/2025 documented that the resident’s cognitive functioning was severely impaired and that the resident required moderate assistance with oral hygiene, toileting hygiene, dressing, and personal hygiene. A physician’s order dated 5/15/2025 directed transfer of the resident to a specific board and care home. The DON reported there was no documented evidence that facility staff evaluated the board and care facility or communicated with it prior to the resident’s discharge. The DON stated staff did not verify that the receiving facility met required standards or could provide necessary care and services, and that staff relied solely on information from the palliative care provider without completing their own assessment and evaluation. The DON acknowledged the resident was inappropriately discharged and placed at risk of not receiving necessary care, including correct medications and pain assessment and management. The facility also failed to involve the resident’s representative in the discharge planning process and to inform him of the final discharge destination. The resident’s POA stated he was initially told the resident would be transferred back to a previous SNF, and that he was not informed when the discharge plan changed and the resident was instead discharged to a board and care home. The POA learned of the actual discharge location two days later after contacting the former administrator. Review of the Notice of Transfer or Discharge and the Discharge Summary, both dated 5/15/2025, showed the resident was unable to sign, and the DON confirmed there was no documentation that the POA received these documents. The DON stated the resident could not make decisions, that risks and benefits of the discharge plan should have been discussed with the POA, and that the facility’s own discharge policy required resident/representative involvement and an individualized post-discharge plan, which did not occur in this case.
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