F0627

D

Incomplete Discharge Planning and Communication for Dependent Resident

Houston, Texas Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe and properly planned discharge for a cognitively impaired, paraplegic female resident with multiple comorbidities, including pressure ulcers, bladder infection, GERD, diabetes with neuropathy, hypertension, generalized muscle weakness, and abnormal gait and mobility. The resident’s MDS and care plan documented moderately impaired cognition, total dependence on staff for lower body dressing, toileting, transfers (including sit-to-stand, bed-to-chair), and wheelchair mobility, as well as complete incontinence of bowel and bladder. She required a mechanical lift for transfers and maximum assistance for bed mobility and lower body ADLs, and therapy records recommended home health services at discharge.

Despite these documented needs, the facility discharged the resident to a personal care home without completing an accurate and comprehensive discharge summary or plan. Progress notes indicated that the social worker had discussed discharge options, including another facility and a personal care home, and that home health had offered to assist upon discharge. However, there was no documentation that the facility obtained or documented the address of the discharge location in the discharge summary, and key sections of the discharge documentation were left blank, including physical functioning and structural problems (mobility devices, self-care, mobility), care team, scheduled appointments, special instructions (dietary/nutrition and therapy), medical equipment, continence, and customary routine. The transition of care/discharge summary did not specify the necessary equipment, such as a mechanical lift or hospital bed, or the services the resident would require after discharge.

The facility also failed to timely communicate the resident’s clinical information and functional limitations to the receiving personal care home and to arrange necessary DME and services prior to discharge. There was no documentation that clinical records were sent to the personal care home before the resident’s transfer, and the discharge packet, including the continuity of care document and discharge summary, was not faxed until six days after the resident left. Interviews with the personal care home owner and transportation staff revealed that the resident arrived to a room with only a low twin bed, no hospital bed, and that the personal care home had not been informed that the resident required maximum assistance and could not transfer herself. The administrator and family member confirmed that the personal care home was not notified of the required DME prior to the resident’s arrival and that there was no documentation of DME orders or home health coordination before discharge, despite facility policy stating that all aspects of transfer and discharge must be documented and that sufficient preparation and orientation must be provided for a safe and orderly transfer or discharge.

The facility’s internal investigation and administrator interview further established that the social worker responsible for the discharge did not order DME or fax a home health referral prior to discharge, and that there was no documentation of clinical information being sent to the personal care home at the time of transfer. The administrator acknowledged that discharge planning should begin at admission and that all services should be initiated prior to discharge, but in this case, the discharge summary was incomplete and lacked essential information such as the discharge destination, needed services, and equipment. The facility’s policy on admission, discharge, and transfer required documentation of all aspects of transfer and discharge, including patient/family notification and physician orders, and required sufficient preparation for a safe and orderly transfer, but the report notes that the policy did not provide further details on coordinating safe and orderly transfers, and the documented practices for this resident did not meet those stated requirements.