Failure to Coordinate Caregiver Support for Safe Discharge Home
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge for a resident who required assistance with activities of daily living and caregiver support at home. The resident had diagnoses including muscle weakness and unsteadiness on feet and, per the discharge plan dated January 12, 2026, required assistance with household tasks such as meal preparation, bill paying, simple cleaning, transfers from bed to chair, and walking. Occupational therapy documented that the resident needed minimal help with feeding, personal hygiene, bathing, dressing, and toilet use, and moderate help with transfers. Physical therapy documented that the resident was to be discharged home with support and assistance from others, including community assistance and caregiver availability in the morning and afternoon. Nursing notes indicated the resident was discharged home on January 14, 2026, with IHSS services. Interviews and record review showed that the Interdisciplinary Team (IDT) did not coordinate or verify the availability, capacity, or adequacy of caregiver support and services prior to discharge. The SSD relied solely on the resident’s report that IHSS services and the daughter’s assistance were in place and did not contact the daughter to confirm caregiver availability or ability to provide care. The resident’s daughter was not included in the discharge planning discussion, and there was no IDT discussion regarding caregiver hours, caregiver training, or the level of assistance required at home. The DOR stated the resident required caregiver support during daytime and nighttime hours and that caregiver training would have been required if a family member were to provide care, but no such training was provided. The DON acknowledged that nursing and rehabilitation did not coordinate discharge needs with Social Services, including caregiver training and required hours, and the resident returned to the facility the day after discharge when the daughter reported that approved IHSS hours were less than anticipated and insufficient to meet the resident’s care needs.
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